^  THI      V 
^  UBRAAIM  S 

HRALiti 


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TEXT-BOOK 

OF 

INSANITY 

-  / 
Based  oit  Clustical  Obseevatioists 

FOR   PRACTITIONERS   AND   STUDENTS 
OF   MEDICINE 


De.  R.  vo:n  Keafft-Ebiistg 

Late  Professor  of  Psychiatry  akd/^krvous  Diseases  in  the  University  of  Vienna 


AUTEORIZED  TEANSLATION   FROM  THE   LAST  GERMAN   EDITION 


CHARLES  GILBERT  CHADDOCK,    M.D. 

Professor  of  Diseases  of  the  Nervous  System  in  the  Marion-Sijis-Beadmont  College  of  Medicine 
Medical  Department  of  St.  Louis  University,  St.  Louis,  Mo. 


With  an  Introduction 

BY 

FREDERICK  PETERSON,  M.D. 

President  of  the  New  York  State  Commission  in  Lunacy 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 
1904 


COPYRIGHT,  DECEMBER,  1904, 

BY 

F.  A.  DAVIS  COMPANY. 
TRegistered  at  Stationers'  Hall,  London.  Eng.] 


Philadelphia.  Pa..  U.  S.A. 

The  Medical  Bulletin  Printing-house, 

1014-16  Cherry  Street. 


PEEFAOE. 


The  present  edition  follows  the  tradition  of  preceding  editions, 
in  that  the  author's  text-book  is  intended  to  be  a  useful  guide  in  the 
difficult  domain  of  psychiatric  study  and  science,  for  the  student  as 
well  as  for  the  practitioner  of  medicine.  For  the  attainment  of  this 
object,  the  important  points  that  ha\  :  been  kept  in  view  are :  Clear, 
comprehensible  terms;  avoidance,  as  far  as  possible,  of  theories  and 
hypotheses;  emphasis  of  all  that  may  be  regarded  as  more  or  less 
certain  in  the  science  of  psychiatry;  and  systematic  arrangement  of 
the  scientific  material. 

Owing  to  the  peculiarity  of  this  science  and  its  state  of  incom- 
pleteness, text-books  on  psychiatry  present  more  or  less  prominently 
subjective  features  dependent  upon  the  personality  of  their  authors. 
The  present  text-book  is  based  upon  thirty-three  years  of  observation 
of  the  insane,  and  presents  disease-pictures  in  the  light  of  the  author's 
personal  experience.  The  general  correspondence  between  the  author's 
experience  and  that  of  other  observers  may  be  taken  as  a  guarantee 
that  in  general  he  has  been  correct  in  his  observation,  and  that,  not- 
withstanding the  confusing  variety  of  manifestations  in  "diseases  of 
the  personality,"  there  are  certain  fixed  laws  which  permit  the  estab- 
lishment empirically  of  distinct  disease-pictures. 

The  most  careful  account  has  been  taken  of  the  additions  to 
psychiatric  science  since  the  last  edition  of  this  work. 

May  the  book  in  its  new  form  again  meet  with  success ! 

The  Authoe. 


(iii) 


TRAITSLATOE^S  PEEFACE. 


The  late  Professor  E.  von  KrafTt-Ebing's  "Psychiatry"  has  long 
deserved  an  English  version  because  of  its  merited  popularity  among 
students  of  insanity.  The  author's  clear  exposition  of  psychology  and 
psychopathology  should  make  the  English  edition  especially  useful  to 
American  students;  and  his  masterly  descriptions  will  facilitate  a 
practical  understanding  of  cases  of  insanity  presented  clinically. 

Our  thanks  are  due  Dr.  Frederick  Peterson,  of  Xew  York,  for 
his  kindness  in  consenting  to  prepare  the  biographical  introduction. 

It  is  hoped  that  the  author's  words  have  been  so  rendered  into 
English  that  his  meaning  is  unchanged,  and  that  the  difficulties  in- 
herent in  the  subject  have  not  been  increased  by  too  close  adherence 
to  the  German  text. 

The  Tkanslator. 


(iv) 


TABLE  OF  CO]SrTE]:^TS. 


BOOK  I. 

Introduction  to  the  Study  of  Psychiatry. 

PAGE 

Part  First. — The  Subject  and  Aids  in  its  Study 1 

Chapter        I.  General  Idea  and  Nature  of  Mental  Disease 1 

Chapter       II.  The  Organ  of  the  Psychic  Functions.  Anatomic  Preliminaries  2 

Chapter     III.  Physiologic  Preliminaries 7 

Chapter      IV.  Psychologic  Preliminaries lö 

Chapter       V.  The  Special  Place  of  Mental  Disease  in  the  General  Domain 

of  Cerebral  Disease   20 

Chapter     VI.  Importance  of  the  Study  of  Psychiatry  24 

Chapter    VII.  Difficulties    and    the    General    Principles    of    the    Study    of 

Mental  Diseases    27 

Chapter  VIII.  Analogies  of  Insanity   29 

Part  Second. — Historic  Review  of  the  Development  of  Psychiatry  as  a 

Science   36 

Chapter         I.  Psychiatry  in  Ancient  Times 37 

Chapter       II.  Psychiatry  in  the  Middle  Ages 39 

Chapter     III.  The  Rehabilitation  of  Psychiatry  at  the  End  of  the  Eight- 
eenth Century   41 

BOOK  II. 
General  Pathology  and  Therapy  of  Insanity. 

Part  First. — Elementary  Anomalies  of  the  Cerebral  Functions  in  Insanity.  47 

Chapter         I.  Elementary  Psychic  Disturbances.    Classification 48 

Chapter       II.  Elementary   Psychic   Disturbances.     Anomalies    of   Feeling 

(Emotions) 48 

*                         1.  Anomalies  in  Content,  Abnormal  States  of  Feeling  ....  49 
2.  Anomalies    (Formal)    in  the   Origin   of  Emotions    (Ab- 
normal Emotional  Reaction)   51 

(a J  Anomalies  of  Emotional  Impressionability 51 

(h)  Anomalies  in  the  Intensity  of  Emotional  Reaction.  .  56 

(cj  Anomalies  in  the  Quality  of  Emotional  Coloring  ...  57 

Chapter     III.  Elementary  Psychic  Disturbances.    Intellectual  Anomalies.  .  59 

1.  Formal  Intellectual  Disturbances  59 

(a)  Disturbance  of  the  Rapidity  of  Ideation  59 

(b)  Disturbances  of  Association 62 

(c)  Distiirbances  in  the  Intensity  and  Duration  of  Ideas. 

Imperative  Ideas 63 

(dj  Disturbances  of  Apperception 66 

(V) 


vi  TABLE  OF  CONTENTS. 

Chapter     III  (Ctmcluäed).  paoe 

1.  Formal  Intellectual   Disturbances   ( Concluded ). 

(e)  Disturbances  AHecling  the  Exactness  of  the  Repro- 

duttiun  of  lileas  (Memory)   CG 

(1 )  Ancfmulies    of    Keproduttiun    of    Ideas    in    Changed 

Form   (Imagination)    70 

2.  Fallacies  in  tlie  Content  of  Ideas  (Delusions)   71 

Chapter      1\'.   Disturbances  of   the   Motor  Side  of  Mental   Life    (Impulse 

and  Will)    7f) 

I.  Disturbances  of  the  Instincts 79 

(a)  Anomalies  of  the  Appetites 79 

(h)  Anomalies  of  the  Sexual  Instinct 81 

,                     2.  Impulsive  Acts  .  . 87 

3.  Psychomotor  Distiubances  88 

(a)  The  Impulsive  Restlessness  of  the  Maniacal 88 

(b)  Psychic  Reflex   Acts  in   Melancholies   and   the   De- 

lirious     90 

(c)  Imperative  IMovements  in  States  of  Mental  Weak- 

ness     90 

(il)  Tetany  91 

(ej  Catalepsy   91 

4.  Disturbances  of  tjie  Will 92 

5.  Disturbances  of  "Free"  Will  95 

Chapter       V.  Disturbances  of  Consciousness  95 

Chapter      VI.  Disturbances  of  Speech  in  Insanity  100 

Chapter    VII.  Psychosensorial  Disturbances  103 

1.  Hallucination    104 

2.  Illusion   Ill 

Deliria  of  the  Senses  in  the  Insane 115 

Chapter  VIII.  Disturbances  of  Sensory  Functions 119 

1.  Anesthesias    1 19 

2.  Hyperesthesias   121 

Chapter      IX.  Disturbances  of  Motor  Functions 124 

Chapter       X.  Disturbances  of  the  Vasomotor  Nerves 126 

Chapter     XL  Disturbances  of  the  Trophic  Functions 129 

Chapter    XII.  Disturbances  of  the  Secretory  Functions 131 

Chapter  XI IL  Disturbances  in  the  Domain  of  the  Vital  Functions 133 

Part  Second. — The  Causes  of  Insanity  136 

I.  Predisposing  Causes    138 

1.  General  Predisposing  Causes  133 

2.  Individual  Predisposing  Causes 157 

II.  Accessory  Causes  165 

1.  Psychic  Causes 165 

2.  Physical  Causes   167 

Part  Thtrd. — Course,  Duration,  Termination,  and  Prognosis  of  Mental 

Disea.ses 199 

Chapter        I.  Course  and  Duration  of  Insanity 199 

1.  Chronic  and  Subacute  Insanity 199 

(u)  Chronic  and  Subacute  Insanity  in  the  Form  of  an 

Isolated  Attack 199 

(hj  Chronic  Insanity  in  tlie  Form  of  Periodic  Attacks.  .  204 


TABLE  OF  CONTENTS.  VÜ 

Chapter         I  (Concluded].  page 

2.  Transitory  Insanity   20ß 

(aj  Transitory  Mania    207 

(b)  Transitory  States  of  i'ear  210 

(cj  Pathologic  States  of  Emotion 212 

(dj  States  of  Pathologic  Reaction  to  Alcohol 214 

Chapter       II.  Morbidity.    Important  Intercurrent  Diseases 216 

Chapter     III.  Prognosis  of  Insanity   220 

1.  Prognosis  of  Life  220 

2.  Prognosis  of  Cure 221 

3.  Prognosis  of  Recurrence  227 

4.  Prognosis  of  Hereditary  Transmission 228 

Part  Fourth. — General  Diagnosis 231 

Chapter        I.  Diagnosis  of  the  Disease 231 

Chapter       II.  Diagnosis  of  Cure 239 

Appendix.     Outline  for  the   Examination  of   tlie  Mental 

Condition   240 

Part  Fifth. — General  Therapy 246 

Chapter        I.  General  Considerations  246 

Chapter       II.  Prophylaxis  of  Insanity  248 

Chapter     III.  Treatment  in  the  Initial  Stages  of  Insanity 250 

Chapter     IV.  The  Hospital  for  the  Insane 252 

Chapter       V.  Treatment  of  the  Fully  Developed  Disease  255 

I.  Somatic  Therapy  by  Physical  and  Chemical  Means  ....   255 

.    1.  Means  to  Prevent  the  Fluxion  of  Blood  to  the  Brain.   255 

(a)  By  Diminishing  the  Quantity  of  Blood — Bleeding.  255 

(ij  To  Diminish  the  Activity  of  the  Heart 256 

(cJ  By  Dilating  the  Peripheral  Vessels 256 

(d)  By  Contracting  the  Cerebral  Vessels 257 

2.  Means  of  Increasing  the  Flow  of  Blood  to  the  Brain. .   257 

(a)  By  Increasing  the  Heart's  Action 257 

(J)J  By  Dilating  the  Blood-vessels 258 

(cJ  By  Facilitating  the  Flow  of  Blood  to  the  Brain .  .   258 

3.  Means  of  Calming  Excitement  and  Excitability 258 

(aJ  General  Calmatives 258 

1.  Narcotics    258 

2.  Physical  and  Dietetic  Calmative  Remedies 262 

(bj  Hypnotics   263 

(cJ  Anaphrodisiacs    266 

4.  Tonics   267 

5.  Diet   ^ 267 

6.  Important  Symptoms 269 

II.  Psychic  Treatment    271 

Treatment  by  Hypnotic  Suggestion 274 

Chapter     VI.  Treatment  During  the  Period  of  Convalescence 275 

BOOK  III. 
Special  Pathology  and  Thekapy  of  Insanity. 

Introduction.^ — Classification  of  the  Psychoses — Forms  of  Insanity 277 

Part  First. — Psychoneuroses — Primary  Curable  States  286 


viii  TABLE  OF  CONTENTS. 

PAGE 

Chapter         I.  ;^rplanoholia    28ü 

1.  Simple  Mi'lamluiliu    29Ü 

(u)  Melancliolia  witliout  Delusion 293 

(b)  Melancholia  witii  Precordial  Distress  295 

(c)  Melancholia     witli     Delusions    and    Errors    of    tlu- 

Senses 298 

1.  Keli-ious   Melancliolia    301 

2.  Hypochondriac  Melancholia    304 

2.  Melancholia    with    Stupor,    or    Melancholia    Attonita 

or  Stupiila  305 

Chapter       II.  Mania   312 

I.  Maniacal  Exaltation  313 

II.  Furious  Mania    319 

Chapter     III.  Stupidity,  or  Primary  Curable  Dementia  330 

(a)  Stupidity  Due  to  Exhaustion  of  the  Psychic  Organ.  . .   330 

(h)  Stupidity  Due  to  Psychic  Shock  336 

(c)  Stupidity  Due  to  Mechanical  Shock  338 

Chapter     IV.  Primary  Hallucinatory  Insanity 340 

Chapter       V.  Secondary  Insanity  and  Terminal  Dementia  350 

1.  Secondary  Delusional  Insanity   351 

2.  Terminal  Dementia  355 

(a)  Agitated  Dementia  (General  Mental  Confusion)  . .  .  355 

(b)  Apathetic  Dementia 356 

Part  Second. — Psychic  Degenerations  359 

Chapter         1.  General  Clinical  Consideration  359 

Chapter       11.  Constitutional  Atiective  Insanity  (Folie  Pvaisonnante)    3G5 

Chapter     111.  Paranoia    368 

I.  Original  Paranoia    377 

II.  Late    (Acquired)   Paranoia    381 

(a)  Persecutory  Paranoia   382 

1.  The  Typic  Form  of  Acquired  Paranoia  382 

2.  Querulous  Insanity  with  Mania  for  Lawsuits 394 

(h)  Expansive  Paranoia   399 

1.  Inventive  Paranoia  399 

2.  Religious  Paranoia    403 

3.  Erotic  Paranoia   (Erotomania)    408 

Chapter      IV.  Periodic  Insanity    413 

I.  Periodic  Insanity  of  Idiopathic  Origin  416 

1.  Idiopathic  Periodic  Insanity  in  the  Form  of  Psycho- 

neuroses   417 

(a)  Periodic  Mania 417 

(b)  Periodic  Melancholia    421 

(e)  Periodic  Hallucinatory  Insanity  424 

(d)  Circular  Insanity   426 

2.  Periodic  Insanity  in  the  Form  of  Morbid  Instincts.  .  433 

(a)  Dipsomania,  or  Periodic  Drunkenness 434 

(h)  Periodic  Recurring  Abnormal  Sexual  Impulse.  .  .  437 

n.  Periodic  Insanity  of  Sympathetic  Origin 438 

Menstrual  Insanity 438 


TABLE  OF  CONTENTS.  ix 

PAGE 

Part  Third. — Mental  Disease  Developing  out  of  Constitutional  Neuroses.   444 
Chapter        I.  Insanity  on  a  Neurasthenic  Foundation  445 

1.  Transitory  Insanity    452 

2.  Protracted  Psychoneurotic  Forms  of  Diseaso   454 

Melancholia  Ma.sturbatoria 454 

3.  Degenerate    Forms    of    Disease    upon    a    Ncurastiieiiic 

Basis   457 

(a)  Mental  Disturbance  Due  to  Imperative  Ideas 457 

(h)  Neurasthenic  Paranoia 466 

Paranoia  (Hexualis)  Masturbatoria 467 

Chapter       II.  Epileptic  Insanity 472 

1.  Epileptic  Psychic  Degeneration  475 

2.  Transitory  Attacks  of  Psychic  Disturbance 477 

(a)  Stupor   478 

(h)  States  of  Clouded  Consciousness  479 

1.  States  of  Clouded  Consciousness  with  Fear 470 

2.  States    of    Clouded    Consciousness    with    Halluci- 

natory Persecutory  Delirium 480 

3.  States   of   Clouded  Consciousness   with   Religious 

Expansive  Delirium   482 

4.  Peculiar    States    of    Clouded    Consciousness    with 

Dreamy  Romantic  Ideas 484 

5.  Confused  States  with  Excitement  in  the  Form  of 

Moria  lasting  Hours  or  Days    485 

3.  Protracted  Equivalents   486 

4.  Chronic  Epileptic  Psj^choses 490 

Chapter     III.  Hysteric  Insanity   492 

1.  States  of  Transitory  Insanity   493 

2.  Protracted  States  of  Hysteric  Delirium  497 

3.  Hysteric  Psychoses  500 

Psychoneuroses 500 

States  of  Psychic  Degeneration   500 

Chapter      IV.  Hypochondriac  Insanity   505 

The  Hypochondriac  Neuropsychosis   506 

States  of  Mental  Weakness  Developed  from  Hj^pochondria  509 

Part  Fourth. — Chronic  Intoxications 512 

Chapter         I.  Chronic  Alcoholism  and  its  Complications   513 

Chapter       II.  Morphinism     540 

Part  Iifth. — Brain  Diseases  with  Predominating  Psychic  Symptoms  ....  546 
Chapter         I.  Acute  Delirium   (Transudative  Hyperemia  in  Transition  to 

Acute  Periencephalitis)    546 

Chapter       IL  Dementia  Paralytica  (Periencephalomeningitis  Difl'usa)   ....  557 

■Chapter     III.  Cerebral  Syphilis 594 

Chapter      IV.  Senile  Dementia 603 

Part  Sixth. — Arrest  of  Psychic  Development 609 

Chapter         I.  Intellectual  Idiocy    610 

Chapter       II.  Moral  Idiocy  (Moral  Insanity)   621 

Index  629 


INDEX  OF  CASES. 


CASE  PAGE 

1.  iFaniacal  Insanity  at  Puberty  with  Hebephrenic  Symptoms.    Recovery  148 

2.  Transitory  Mania  due  to  Caloric  Influences   209 

3.  Transitory  Fear  on  a  Neurasthenic  Foundation 211 

4.  Confusion,  Followed  by  Stupor,  due  to  Fright 214 

5.  Delirious  State  of  Semiconsciousness  after  Indulgence  in  Alcohol 215 

G.  Melancholia  Without  Delusion  due  to  Chronic  Intestinal  Catarrh  and 

Neurasthenia    293 

7.  Chronic  Melancholia,  with  Raptus  Melancholicus,  due  to  Exhausting 

Causes  297 

8.  Agitated  Melancholia;    Good  Result  from  Treatment  with  Upiuni 2iJ9 

9.  Religious  Melancholia 302 

10.  Melancholia  with  Stupor ;    Tetanj' 307 

11.  Maniacal  Exaltation  during  the  Puerperium  317 

12.  Acute  Angry  Mania  Initiated  by  an  Outburst  of  Anger 327 

13.  Mania  with  Occasional  Nymphomania  328 

14.  Stupidity  due  to  Enfeebling  Phj'sical  Causes  335 

15.  Stupidity  due  to  Mental  Shock 337 

16.  Stupidity  due  to  Mechanical  Shock  338 

17.  Postfebrile  Acute  Hallucinatory  Insanity   348 

18.  Acute  Hallucinatory  Insanity   348 

19.  Furious  Mania;    Termination  in  Secondary  Insanity 353 

20.  Furious  Mania;    Termination  in  Apathetic  Dementia  357 

21.  Melancholic  Folie  Raisonnante.     Interesting  Description  of  the  Condi- 

tion by  the  Patient 366 

22.  Original  Paranoia   379 

23.  Typic  Form  of  Acquired  Paranoia.    Outbreak  during  the  Climacteric.  . .   387 

24.  Paranoia  Sexualis   391 

25.  Paranoia  Sexualis  (Delusions  of  Jealousy  in  a  Wife)   392 

26.  Paranoia  Sexualis  (Delusions  of  Jealousy  in  a  Husband)   394 

27.  Querulous  Insanity ;    later  Delusions  of  Poisoning  and  Persecution ....   397 

28.  Reformatory  Paranoia 401 

29.  Religious  Paranoia  406 

30.  Erotic  Paranoia  (Male)    409 

31.  Erotic  Paranoia  (Female)   411 

32.  Periodic  Mania,  with  Long  Attacks  and  Long  Intervals 420 

33.  Periodic  Melancholia    422 

34.  Periodic  Hallucinatory  Insanity  ." 424 

35.  Circular  (Melancholico-maniacal)  Insanity;    Phases  of  Several  Months' 

Duration    428 

30.  Circular  Insanity  in  tlie  Form  of  Alternating  Pliases   of  Mania  and 

Stupor 432 

37.  Dipsomania    436 


INDEX  OF  CASES.  xi 

CASE  PAGE 

38.  Periodic  Menstrual  Mania   441 

39.  Transitoiy  Neurasthenic  Insanity;   Delirium  witli   Self-accusation....  453 

40.  Melancholia  due  to  Onanism 456 

41.  Insanity  due  to  Imperative  Ideas 464 

42.  Paranoia  Masturbatoria   469 

43.  Paranoia  upon  the  Foundation  of  Sexual  Neurasthenia  in  the  Climac- 

teric    471 

44.  Epileptic  Stupor 478 

45.  States  of  Epileptic  Clouding  of  Consciousness  with  Apprehension  (Petit 

Mal)  479 

46.  Delirious  Post-epileptic  States  of  Clouded  Consciousness  (Grand  Mai).  481 

47.  Post-epileptic  States  of  Frightful  Delirium  and  Fragments  of  Religious 

Expansive  Delirium 482 

48.  Epileptic  Religio-expansive  Delirium 483 

49.  Epileptic   Dream-states    484 

50.  Epileptic  States  of  Confusion  with  Excitement  in  the  Form  of  Moria .  .  485 

51.  Protracted  Post-epileptic  Delirium   487 

52.  Hysteria;  Ecstatic  States  of  Exaltation  Associated  with  Frightful  De- 

lirious States. 1 495 

53.  Hysteric  States  of  Exaltation,  with  Imperative  and  Facilitated  Ilepro- 

duction  495 

54.  Hysteria  after  Violation.    Attacks  of  Hystero-epileptic  Frightful  Hal- 

lucinatory Delirium    496 

55.  Hysteric  Protracted  Hallucinatory  Delirium   498 

56.  Original  Paranoia  on  Hysteric  Basis.     Transformation  through  Hys- 

teric Delirious  States 502 

57.  Hysteric  Paranoia   (Sensations)    504 

58.  Mental  Weakness  due  to  Hypochondria  509 

59.  Chronic   Alcoholism   with    Remarkable    Degeneration    of    Morals    and 

Character  (Inhumanitas  and  Ferocitas  EbriosaJ.    Brutality  to  the 

Wife  in  a  Condition  of  Drunkenness  and  Excitement 518 

60.  Delirium  Tremens.    Treatment  with  Morphine  and  Chloral 525 

61.  Alcoholic  Hallucinations;    Wife-murder 526 

62.  Alcoholic  Melancholia    528 

63.  Mania  Gravis  Potatorum;   Death   532 

64.  Alcoholic  Persecutory  Hallucinatory  Insanity 534 

65.  Alcoholic  Paranoia   536 

66.  Alcoholic  Paralysis;   Recovery   537 

67.  Alcoholic  Epilepsy;    Combined   Delirium    Tremens    and    Epileptic    De- 

lirium     539 

68.  Morphinism 544 

69.  Morphinism  545 

70.  Acute  Delirium 553 

71.  Acute  Delirium;   Treatment  with  Ergotine;   Recovery 555 

72.  Acute  Paralysis   587 

73.  Classic  Paralysis ;   Subacute  Course   588 

74.  Hypochondriac  Form  of  Paralysis;  After  a  Remission  it  takes  on  the 

Classic  Form;  After  Another  Profound  Remission,  Recurrence  of 

the  Hypochondriac  Form   590 


xii  INDEX  OF  CASES. 

CASE                                                                                                                                                                          PAGE 
75.  Priniarv  Progressive  Dementia  Paralytica  Followinjj  Mental  OverMork.   592 
70.  Cerebral  Lues  Reseinliling  tlie  Disease-picture  of  Dementia  Paralytica; 
Iniprovcincnt    under  Specific  Treatment;    Exacerbation    Ending  in 
Deatli   598 

77.  Progressive    Dementia    with    Motor    Disturbances,    of    Luetic    ()ri<;iM; 

Treatment  with  Potassium   Iodide;    Lasting  Improvement    001 

78.  Senile  Melancholia;  Termination  in  Senile  Dementia   605 

79.  Senile  Dementia;   Intercurrent  Mania   GOO 

80.  Senile  Dementia ;   Delusions  of  Persecution 007 

81.  Moral    Insanity    027 


II^TEODUOTIOlSr. 


There  is  perhaps  no  other  work  on  psychiatry  in  any  langnage 
which  has  had  the  vogue,  the  wide  distribution,  and  the  popularity 
of  this  of  Krafft-Ebing.  It  has  been  pre-eminently  the  clinical  text- 
book of  insanity  for  many  years  among  most  of  the  Continental  uni- 
versities. It  is  still  a  leading  German  text-book,  despite  the  advent 
of  other  works  which  have  opened  new  vistas  in  an  obscure  field  of 
general  medicine.  There  is  no  better  practical  clinical  exposition  of 
the  facts  of  morbid  psychology,  and  as  such  this  translation  should 
be  of  service  to  the  general  practitioners  and  medical  students  of 
our  own  land.  Those  who  had  the  pleasure  to  sit  under  Krafft-Ebing 
as  a  teacher  of  Gratz  or  "Vienna  will  always  remember  the  clear  and 
concise  explications  of  this  brilliant  psychiatrist. 

Krafft-Ebing  died  December  33,  1903,  at  Gratz  after  thirty 
years  of  teaching  and  after  a  long  life  devoted  to  the  zealous  pursuit 
of  knowledge  and  the  advancement  of  his  specialty.  Among  the 
many  biographic  sketches  published  after  Ms  death  that  oi  H. 
Schule,  written  for  the  Allgemeine  Zeitschrift  für  Psychiatrie  for 
May,  1903,  is  especially  full  and  sympathetic,  having  been  written  by 
one  who  was  a  companion  and  confrere  from  the  very  beginning  of 
the  author's  career.  The  writer  is  indebted  to  Schiile's  article  for 
most  of  the  data  of  this  "Introduction." 

Krafft-Ebing  was  born  at  Mannheim,  August  11,  1840,  and  was 
68  years  old  at  the  time  of  his  death.  He  was  the  oldest  of  four 
children.  His  father  was  a  man  of  noble  nature  and  culture,  be- 
longing to  the  higher  official  circles;  his  mother  a  well-bred  and 
.highly  educated  woman,  a  daughter  of  Mittermaier,  the  great  lawyer 
and  propagandist  of  modern  humane  jurisprudence.  Mittermaier's 
household  at  Heidelberg  was  one  of  the  centers  of  social  and  intel- 
lectual life,  and  as  a  student  in  this  university  Krafft-Ebing  found 
at  his  grandfather's  a  stimulating  mental  atmosphere  that  doubtless 

(xiii) 


xiv  INTRODUCTION. 

tad  much  to  do  with  liis  later  predilection  for  legal  pathology.  He 
became  an  assistant  to  Friedreich,  and  a  summer  at  Zurich  under 
Griesinger  determined  the  choice  of  his  special  field  of  work. 

In  1863  he  went  to  Illenau  to  become  the  assistant  of  Roller 
and  at  the  "same  time  colleague  of  H.  Schule  and  Kirn.  Here  he  be- 
came active  from  morning  till  night  in  an  ideal  atmosphere,  and 
here  prepared  his  graduation  thesis  on  "Sensory  Delirium.^'  After  a 
summer  in  Berlin  he  returned  for  a  period  of  five  years  to  his  prac- 
tical and  scientific  work  at  Illenau.  He  became  a  most  careful  and 
painstaking  clinician.  He  weighed  every  psychic  and  somatic  symp- 
tom, seeking  the  inner  connections  in  the  evolution  of  mental  dis- 
orders by  the  minutest  study  of  the  changes  in  physical  and  mental 
condition 'and  by  the  preparation  of  most  complete  histories  of  his 
cases.  By  the  use  of  this  rigid  inductive  method  he  constructed 
definite  clinical  pictures  which  sought  to  delineate  each  case  from  its 
individual  features.  He  was  not  satisfied  with  a  mere  general  diag- 
nosis for  purposes  of  classification.  He  followed  in  this  the  method 
of  the  venerable  Hergt,  whose  thoroughness  and  devotion  to  his  pro- 
fession and  whose  inimitable  pains  with  each  individual  patient 
were  a  great  inspiration.  The  method  was  new  then,  but  to-day  its 
value  is  self-evident  and  has  become  general  property.  In  those  days, 
in  the  beginning  of  the  sixties,  it  had  to  make  its  way  slowly. 

The  ideas  of  Griesinger,  Jacobi's  inexhaustible  work  on  men- 
tal disorders,  Spielmann's  thoughtful  work  on  diagnoses,  Jessen's 
brilliant  and  thorough  articles  in  the  Berlin  encyclopedia,  and  the 
works  of  Pinel  and  Esquirol,  these  together  formed  the  founda- 
tion of  the  structure  upon  which  Krafft-Ebing  and  his  fellow-stu- 
dents began  their  own  work,  while  at  the  same  time  Wundt's  lec- 
tures on  the  soul  of  man  and  animals,  Fechner's  psychophysics,  the 
discovery  of  vascular  nerves,  and  Morel's  theory  of  heredity  were 
an  additional  source  of  inspiration.  If  the  vasomotor  system  may 
be  called  a  system  of  psychic  nerves  whose  participation  cannot  be 
separated  from  the  genesis  of  morbid  emotional  states,  since  they 
are  a  psychologic  postulate  on  account  of  their  influence  on  the  cen- 
tral circulation,  the  thought  seemed  to  be  justified  that  the  physical 
foundation  for  many  of  the  affective  psychoses  lay  in  disorders  of 
the  vasomotor  system.  On  the  other  hand,  the  creative  mind  of 
Morel,  in  his  theory  of  heredity,  emphasized  the  importance  of  sim- 
ple disposition  and  degeneration,  thus  connecting  etiologically  the 
facts  of  individual  endowments  and  differences  with  definite  pecul- 
iarities and  modifications  in  the  evolution  of  psychic  disorders,  and 
delineating  certain   aberrant  types   of   course   and   outcome   among 


INTRODUCTION.  XV 

the  so-called  hereditary  psychoses.  "ISTormal  being"  and  ''superior 
and  inferior  beings"  became  at  the  time  common  phrases,  serving 
as  categories  under  which  all  new  cases  were  ranged. 

Krafft-Ebing  was  indefatigable  in  his  work.  He  never  spared 
himself.  Whenever  possible  he  made  most  careful  pedigrees  of  all 
his  cases.  Every  detail  in  the  symptom-complex,  every  peculiarity 
in  the  course  of  a  mental  disorder,  was  again  and  again  studied  in 
the  light  of  the  principles  of  natural  science,  in  order  to  make 
critical  comparisons  of  results,  to  extend  the  principles  derived,  and 
to  test  them  over  and  over  in  relation  to  diversities  and  exceptions. 
It  may  be  well  stated  that  the  anthropologic  clinical  point  of  view 
in  pathogenesis  introduced  by  Morel  was  taken  up  by  Ivrafft-Ebing, 
greatly  elaborated,  and  made  by  him  the  general  property  of  our 
science.  In  this  manner  the  psychoses  came  to  be  grouped  as  vaso- 
motor cerebral  neuroses,  psychoses  founded  on  defective  develop- 
ment of  the  brain  or  on  the  invalid  brain,  and  psychoses  associated 
with  organic  brain  disease.  His  exceedingly  conscientious  histories 
led  to  an  excellent  system  of  clinical  symptomatology  in  which  the 
symptoms  gained  a  diagnostic  and  prognostic  value.  In  his  personal 
relations  with  his  patients  he  exhibited  the  gift  of  keen  sympathy 
and  the  most  kindly  interest.  He  would  spend  entire  afternoons  in 
the  garden  with  restless  patients  to  show  how  much  easier  it  was  to 
do  without  restraint,  he  would  play  the  piano  for  their  entertainment, 
and  in  many  other  ways  show  evidence  of  personal  care  and  interest. 
During  his  stay  at  lUenau  he  wrote  a  number  of  monographs, 
among  them  being  one  on  psychic  disorders  after  trauma  to  the 
head,  and  others  on  transitory  mania,  melancholia,  transitory  dis- 
orders of  self-consciousness,  and  the  recognition  of  doubtful  mental 
states.  In  this  last  he  demonstrated  for  the  first  time  the  clinical 
features  of  "imperative  concepts." 

I  In  1869  he  was  for  a  time  a  neurologist  in  Baden,  and  then  en- 
tered the  army,  serving  in  his  professional  capacity  during  the 
Franco-German  war.  Shortly  after  this  he  was  offered  and  ac- 
cepted the  position  of  Professor  of  Psychiatry  in  the  new  German 
Univ,ersity  of  Strassburg,  holding  this  post  till  1873,  when  he  was 
called  to  Gratz  to  become  director  of  the  new  hospital  for  the  in- 
sane there  and  teacher  in  the  medical  school.  In  1875  the  first  edi- 
tion of  his  "Forensic  Psychiatry"  appeared,  a  book  which  accom- 
plished in  its  field  what  Griesinger  has  carried  out  in  the  purely  clin- 
ical domain.  He  looked  upon  crime  as  an  act  of  will;  but,  in  the 
place  of  a  deduction  from  an  abstract  idea  of  guilt,  he  attempted  to 
explain  inductively  how  the  deed  is  the  result  of  a  condition  in  the 


xvi  INTRODUCTION. 

criminal  \\lii(h  it  should  ])v  llic  task  of  the  jiliysiiian  to  establish. 
In  18Tt)  ho  puhlishod  the  first  edition  of  this  "'rcxf-hook  of  I'svchi- 
atry,"  and  edition  followed  edition.  iL  was  translated  into  many 
foreign  languages. 

During  his  stay  in  Gratz  our  author  l)egan  to  interest  himself  in 
hypnotism  and  he  sketched  out  that  volume  on  "Psychopathia  Sex- 
ualis"  which  brought  him  both  recognition  and  much  criticism.  He 
also  demonstrated  dream  states  in  neurasthenia;  and  a  great  many 
articles  on  hysteria,  epilepsy,  and  other  similar  subjects  gave  evidence 
of  his  activity  in  the  field  of  neuropathology. 

In  the  beginning  of  the  eighties  he  retired  from  the  director- 
ship of  the  asylum  at  Gratz,  devoting  liimsclf  to  his  professorship 
and  a  clinic  on  nervous  diseases  witli  twenty-four  beds.  Besides 
this  he  founded  a  sanitarium  near  (iratz  pi'csidcd  over  by  two  able 
pupils. 

In  1889  he  was  called  to  Vienna,  and  three  years  hiter  succeeded 
Meynert  in  the  most  important  professorship  of  psychiatry  at  the 
time  in  the  world.  This  became  the  goklen  period  of  his  life. 
Honors  and  recognitions  were  showered  upon  him,  not  only  in  his 
own    country,    but   by    many    professional    bodies    and    associations 

abroad. 

Feedekick  Peterson. 


BOOK  L 

Introduction  to  the  Study  of  Psychiatry. 


PART  FIRST. 
The  Subject  and  Aids  in  its  Study. 


CHAPTER  I. 
General  Idea  and  Nature  of  Mental  Disease. 

Clinical  psychiatry  is  an  empirical  science  forming  a  part  of 
nervous  pathology.  Its  subject  is  the  conditions  and  phenomena 
which  attend  deviations  of  the  mental  functions  from  the  normal 
standard,  and  the  study  of  the  means  by  which  a  return  of  the  dis- 
turbed functions  to  their  normal  state  may  be  induced.  These  dis- 
eases of  the  brain,  with  predominating  disturbances  of  the  mental 
functions,  are  called  diseases  of  the  mind,  or  mental  diseases.  The 
controversy  concerning  the  existence  of  the  soul  is  absolutely  foreign 
to  the  psychiatry  of  to-day  regarded  as  a  natural  science  founded  on 
empirical  methods  of  study.  For  psychiatry  the  word  soul  stands  only 
as  an  expression  for  the  totality  of  mental  functions  as  manifested 
during  the  time  of  individual  existence.  The  relation  that  exists 
between  the  individual  and  the  soul  (or  mind)  before  it  has  been 
functionally  manifested,  and  the  question  whether  the  soul  lives  on 
after  the  extinction  of  the  life  of  the  body,  psychiatry  relegates  to 
metaphysics  and  theology. 

Better  than  the  expression  "diseases  of  the  mind"  as  a  designa- 
tion for  the  subject  of  psychiatry  is  the  term  "insanity,"  which,  while 
assuming  nothing,  is  yet  strongly  objective. 

The  scientific  idea  of  the  mind  as  a  functional  phenomenon  of 
individual  existence  necessarily  leads  to  the  question  of  what  place 
in  the  body  has  for  its  function  the  manifestation  of  psychic  activity — 
to  the  question  of  the  organ  of  the  mind. 


2  INTRODUCTION  TO  THE  STUDY  OF  rSYC'HIATRY. 

CHAPTER  11. 

The  Organ  of  the  Psychic  Functions.     Anatomic  Preliminaries. 

Scientific  inquiry  has  determined  the  cortex  of  the  cerebrum 
as  the  organ  of  the  psychic  activities,  without  prejudice  to  the  remain- 
ing parts  of  the  central  nervous  system  and  the  peripl\eral  nerves  as 
the  subordinate  mechanisms  and  paths  lor  the  origin  and  distribution 
of  the  psychic  activities. 

Justification  for  the  idea  that  the  cerebral  cortex,  in  the  narrower 
sense,  is  the  place  of  origin  of  mental  functions  is  found  by  science  in 
an  abundance  of  facts  of  descriptive  and  microscopic  anatomy  of  tlie 
human  brain;  in  comparative  anatomy  and  pathology;  and  more  than 
all,  in  the  ijiore  recent  investigations  in  physiology,  which  prove  the 
cerebral  cortex  to  he  the  exclusive  locality  in  which  perceptions  occur 
and  impulses  to  voluntary  movements  originate.  "Memory-pictures" 
likewise  are  there  stored  away  as  residua  of  earlier  sensations,  per- 
ceptions, and  voluntary  movements.  Since,  however,  all  mental 
action  has  its  origin  in  sense-perception,  and  is  inevitably  joined  to 
it,  the  workshop  of  thought  (perception,  as  the  blending  of  a  new 
sense-impression  with  the  memory-picture  of  an  earlier  one;  of 
memory,  as  the  reproduction  of  memory-pictures;  of  intelligence,  as 
the  associative  valuation  of  disparate  memory-pictures)  can  only  be 
the  cerebral  cortex.  That  the  cerebral  hemispheres  are  the  organs 
within  which  the  psychic  activities  arise  has  long  been  taught  by  com- 
parative anatomy  in  that  it  proves  that  the  relative  size  of  the 
cerebral  hemispheres  and  the  basal  ganglia  (corpora  quadrigemina) 
rises  in  favor  of  the  former  just  in  proportion  as  the  psychic  endow- 
ments of  the  various  species  become  more  elaborate. 

Johannes  Müller  proved  this  by  means  of  comparative  anatomy. 
Thus,  in  frogs,  for  example,  the  corpora  quadrigemina  form  the  largest 
part  of  the  cerebrum,  and  far  exceed  in  mass  the  hemispheres,  which 
scarcely  reach  backward  to  the  ganglia. 

In  the  turtle  the  more  highly  developed  hemispheres  attain  the 
corpora  quadrigemina;  in  chickens  they  reach  backward  to  the  cere- 
bellum and  partly  cover  the  corpora  quadrigemina;  in  the  dog  the 
corpora  are  relatively  small  and  are  completely  covered  by  the  hemi- 
spheres. 

An  interesting  confirmation  of  this  fact  is  the  discovery  by 
lileynert  that  the  proportional  mass  of  the  crusta  and  tegmentum  of 
the  crura  cerebri  in  the  animal  series  upward  to  man  corresponds  with 
the  relative  development  which  the  hemispheres  and  mesocephalou  bear 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  3 

to  each  other.  He  ascertained  that,  just  in  proportion  as  Iho  hemi- 
spheres increase  in  size,  the  transverse  section  of  the  crus  (direct  path 
to  the  forebrain  and  path  for  voluntary  movements)  increases;  and 
that  the  transverse  section  of  the  tegmentum  (direct  path  to  the 
mesocephalon)  lessens  in  size  proportionally  with  the  decrease  in  size 
of  the  corpora  quadrigemina  and  optic  thalami. 

These  facts  of  comparative  anatomy  justify  the  conclusion  that 
the  development  of  one  part  of  the  brain  stands  in  relation  to  the 
physiologic  significance  of  that  part  in  the  particular  species. 

The  great  size  of  the  olfactory  lobes  in  certain  animals  dis- 
tinguished for  acuteness  of  the  sense  of  smell  in  comparison  with 
their  small  size  in  man,  in  whose  mental  life  the  olfactory  sense  plays 
a  subordinate  role,  serves  as  a  confirmation  of  this  presumption. 

In  the  comparative  study  of  the  cerebral  hemispheres  of  the 
various  classes  of  mammalia  we  learn  that  the  great  development  of 
them  takes  place  especially  in  the  forebrain;  and,  further,  that  the 
convolutions  lying  about  the  fissure  of  Sylvius,  which  both  physiology 
and  pathology  show  distinctly  to  be  the  center  of  speech,  undergo  a 
peculiarly  perfect  development  in  man. 

Therefore  the  forebrain  is  considered  by  the  most  distinguished 
investigators  (Meynert  and  others)  to  be  the  essential  organ  of  the 
psychic  functions   (consciousness,  will). 

Moreover,  the  important  significance  of  the  forebrain  for  the 
intellect  is  shown,  among  other  things,  by  the  proportional  increase 
of  its  mass  the  higher  the  race  or  the  individual  stands  mentally,  and 
also  by  Meynert's  weighings  of  the  brains  of  the  insane,  according 
to  which  the  forebrain  suffers  the  greater  loss. 

The  surface  of  the  brain  appears  folded  and  furrowed,  and  com- 
parison of  the  external  surface  of  the  human  brain  with  that  of  the 
brains  of  the  various  mammalia  shows  that,  together  with  a  progressive 
development  of  the  mass  of  the  forebrain,  a  constantly  richer  folding 
and  furrowing  of  its  surface  takes  place  the  higher  the  psychic  develop- 
ment in  the  various  species  of  the  animal  kingdom. 

Thus  it  is  possible  to  demonstrate  a  continuous  series  of  brain 
organizations  progressing  from  the  simplest  to  the  most  complete 
types — a  fact  which  was  recognized  and  most  successfully  utilized  by 
Gratiolet. 

The  lowest  orders  of  mammalia  in  which  convolutions  first  make 
their  appearance  include  the  insectivora,  rodentia,  bats,  etc.  The 
entire  furrowing  in  these  animals  is  limited  to  the  formation  of  the 
Sylvian  fissure.  In  the  lepus,  castor,  etc.,  there  is  also  a  longitudinal 
sulcus  running  parallel  with  the  fissure  between  the  two  hemispheres. 


4  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

In  the  fox,  dog,  and  wolf  three  arched  sulci,  placed  around  the 
Sylvian  fissure,  appear  on  each  hemipphcre,  and  thus  form  four  con- 
volutions. 

Since  the  furrowing  of  the  brain  of  the  human  fetus  appears  first 
in  tliis  form,  and  since  these  convolutions  form  the  basis  of  the 
system  of  convolutions  of  all  the  higher  classes  of  animals,  they  have 
been  called  the  primitive  convolutions.  From  the  elephant  upward 
the  brain  assumes  a  higher  type,  in  that  a  great  fissure,  arising  in  the 
parietal  region  next  to  the  longitudinal  fissure,  and  running  thence  to 
the  Sylvian  fissure,  makes  its  appearance,  and  thus  intersects  obliquely 
all  the  primitive  convolutions  running  from  the  frontal  to  the  tem- 
poral region:  i.e.,  those  convolutions  that  lie  around  the  Sylvian 
fissure.  This  is  the  fissure  of  Eolando.  By  it  the  cerebral  cortex  is 
given  two  new  convolutions — the  anterior  and  posterior  central  con- 
volutions. In  the  brains  of  the  more  highly  developed  apes  two  other 
fissures  appear:  the  occipital,  a  deep  fissure  running  outward  from 
the  longitudinal  fissure  in  an  arch  with  its  convexity  backward,  almost 
separating  the  pointed  occipital  lobe;  and  the  sulcus  hippocampi, 
which  lies  farther  back  and  cuts  into  the  occipital  lobe  nearer  its  pos- 
terior extremity. 

The  furrowing  of  the  external  surface  of  the  human  brain  fol- 
lows the  same  plan  as  that  seen  in  the  apes  and  higher  beasts  of  prey, 
but  there  is,  in  addition,  a  secondary  series  of  infoldings,  differing  in 
different  individuals,  starting  from  the  primary  furrows,  and  the 
frontal  lobes  attain  a  development  that  is  not  reached  in  the  lower 
orders. 

The  significance  of  these  furrows  is  shown  in  that  they  are  cov- 
ered with  gray  matter.  The  more  richly  a  brain  is  folded  and  fur- 
rowed, the  greater  its  superficial  extent  must  be  and  the  greater  the 
amount  of  gray  matter. 

The  presumption  is  at  once  suggested  that  .the  increase  of  gray 
matter  and  the  parallel  increase  of  psychic  power  stand  in  relation  to 
each  other. 

This  conclusion,  drawn  from  the  facts  of  comparative  anatomy 
and  psychology,  also  finds  support  in  the  facts  of  anthropology  and 
human  psychology,  for,  the  higher  a  race  stands  in  the  scale  of  develop- 
ment, the  more  complete  and  rich  the  cerebral  convolutions  are  in  its 
representatives.  Too,  in  individuals  of  the  same  race  this  relation  of 
mass  of  cortex  and  intellect  holds  good,  for  greater  mental  endow- 
ment is  accompanied  by  a  corresponding  richness  of  secondary  and 
tertiary  convolutions,  especially  in  the  forebrain.  Embryology  shows 
also  that  the  differentiation  of  the  furrows  and  convolutions  of  the 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY,  5 

cerebral  cortex  of  the  newborn  is  very  inconipletc,  that  it  progresses 
correspondingly  with  the  progressive  development  of  intelligence,  and 
is  only  completed  at  about  the  twenty-first  year  of  life. 

The  significance  of  the  convolutions  is  further  shown  by  the 
brains  of  certain  idiots,  in  which  the  great  poverty  of  cerebral  con- 
volutions— an  arrest  of  their  growth  at  almost  a  fetal  stage  of  develop- 
ment— is  regarded  as  the  substratum  of  the  mental  deficiency. 

The  structure  of  the  cerebral  cortex  is  exceedingly  complex. 
According  to  Meynert's  estimate,  from  five  hundred  million  to  eight 
hundred  million  ganglion-cells  are  here  imbedded  in  a  connective- 
tissue  stroma  extremely  rich  in  blood.  Probably  these  millions  of  cells 
are  interconnected.  Certainly  there  are  regions  of  functionally  related 
cell-groups  forming  complete  convolutional  systems  of  the  cortex,  con- 
nected with  one  another  by  arching  fibers  which  run  from  convolution 
to  convolution  (fibrse  arcuatge  Arnoldi — Meynert^s  association-fibers). 

Besides,  systems  of  commissural  fibers,  stretching  between  and 
spreading  out  in  the  hemispheres,  establish  connections  between  the 
two  halves  of  the  cerebrum.  It  is  probable  that  a  process  passes  out 
from  every  cell  of  the  cerebral  cortex  and  becomes  continuous  with  the 
axis-cylinder  of  a  nerve-tube. 

These  nerve-tubes  collect  into  fibers  and  bundles,  which  may  be 
followed  in  the  hardened  brain  by  means  of  tearing  and  unraveling. 

Facts  disclosed  by  so-called  secondary  degeneration  after  localized 
lesions,  and  the  beautiful  experiments  of  Flechsig,  which  show  that 
the  various  systems  of  fibers  receive  their  sheaths  at  different  periods 
of  fetal  and  postfetal  life,  complete  the  results  obtained  by  coarse 
anatomic  unraveling  or  tearing.  Also  by  Gudden's  vivisections,  caus- 
ing atrophy  of  certain  systems  of  fibers  after  destruction  of  certain 
portions  of  the  brain,  the  anatomic  connections  and  functional  rela- 
tions of  certain  portions  of  the  cerebral  cortex  are  demonstrated. 

Owing  to  the  great  amount  of  work  it  does,  the  brain,  and  espe- 
cially its  cortex,  requires  an  abundant  and  unobstructed  supply  of 
blood,  v/ith  favorable  channels  for  the  removal  of  the  waste-products 
of  tissue-change. 

The  principal  system  of  vessels  for  the  supply  of  blood  to  the 
brain  is  that  of  the  carotids.  After  its  passage  through  the  cavernous 
sinus  the  carotid  divides  into  two  branches.  One  of  these,  the  anterior 
cerebral,  is  destined  for  the  inferior  and  median  surface  of  the  frontal 
lobe,  and  divides  into  three  branches:  (a)  for  the  first  and  second 
frontal  convolutions;  (b)  for  the  gyrus  forni^atus,  corpus  callosum, 
the  first  and  second  orbital  convolutions,  the  superior  extremity  of  the 
ascending  frontal  convolution,  and  the  paracental  lobule ;  and  (c)  for 


6  IXTllODUCTION   TO  THE  STUDY  OF  PSYCHIATRY, 

the  quadrate  lobule.  The  other  branch  of  the  carotid  is  the  middle 
cerebral  artery.  This  supplies  the  remainder  of  the  frontal  lobe  and 
the  entire  parietal  lobe,  dividing  into  four  branches,  named,  in  Buret's 
terminology:  (a)  anterior  inferior  frontal,  for  the  third  frontal  con- 
volution; (b)  anterior  parietal,  for  the  anterior  central  convolution; 
(c)  posterior  parietal,  for  the  posterior  central  convolution ;  and  (d) 
posterior  temporal:  for  the  angular  gyrus  and  the  first  temporal  con- 
volution. 

The  remaining  parts  of  the  cerebrum — its  inferior  surface,  the 
occipital  lobe,  and  the  other  temporal  convolutions — are  supplied  with 
blood  from  the  basilar  artery  (the  vertebral  domain)  through  the 
posterior  cerebral  artery,  with  three  branches:  (a)  for  the  uncinate 
gyrus;  (h)  for  the  inferior  temporal  gyrus  and  fusiform  lobule;  and 
(cj  for  the  lingual  lobule,  euneus,  and  occipital  lobe. 

These  three  principal  arteries  (anterior,  middle,  and  posterior 
cerebral)  run  from  their  origin  at  the  base  at  first  in  the  subarachnoid 
space  and  later  in  the  pia  mater  without  forming  regular  anastomoses 
with  one  another  (Duret).  They  branch  in  the  form  of  a  bush,  send- 
ing arteries  to  nourish  the  cortex  from  the  inner  surface  of  the  pia 
directly  into  the  gray  matter,  which,  in  contradistinction  from  the 
end-arteries  of  the  base,  soon  after  their  origin  form  capillaries. 
Some  of  these  vessels  end  at  once  in  the  cortex,  forming  a  wedge- 
shaped  network  of  capillaries.  The  vessels  that  do  not  end  in  the 
cortex  penetrate  about  three  or  four  centimeters  into  the  medullary 
substance  (medullary  arteries).  Each  convolution  has  from  twelve  to 
fifteen  of  the  latter.  They  anastomose  but  little,  and  not  at  all 
with  the  systems  of  end-arteries  that  pass  upward  from  the  basal 
ganglia  to  the  cortex.  Thus,  by  this  regional  division  of  vascular 
supply,  relatively  independent  for  the  various  parts  of  the  brain,  the 
occurrence  of  circimiscribed  hyperemias  {e.g.,  cortex  as  compared 
with  the  basal  ganglia)  is  favored,  and  even  the  occurrence  of  cir- 
cumscribed (functional)  hyperemias  {e.g.,  in  the  cortex)  is  made  pos- 
sible. The  cerebral  cortex  seems  to  be  specially  protected  against 
fluxionary  hyperemia  by  the  greater  part  of  the  arteries  of  the  pia 
emptying  directly  into  veins,  as  was  found  by  Sehröder  Van  der  Kolk 
and  lately  confirmed  by  Heubner  (derivative  plexus  as  distinguished 
from  the  nutritive  plexus  of  the  cortex).  By  this  means  it  is  pos- 
sible for  a  vascular  storm  to  pass  through  these  into  the  pia  without 
injury  to  the  cortex.  The  return  of  venous  blood  from  the  brain 
takes  place  through  the  sinuses  of  the  dura  mater.  The  most 
important  are  the  transverse  sinus,  which  by  way  of  the  longi- 
tudinal sinus  receives  the  venous  blood  from  the  cortex,  and  the 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  7 

straight  sinus,  which  from  the  great  veins  of  Galen  takes  the  blood 
coming  from  the  internal  surface  of  the  ventricles  and  the  inner 
portions  of  the  brain  in  general. 

Knowledge  of  the  channels  for  the  removal  of  waste-products 
is  of  great  importance.-  Only  of  late  (Key  and  Eetzius,  Schwalbe) 
has  the  desired  clearness  of  knowledge  with  reference  to  the  lymphatic 
vessels  of  the  brain  been  obtained. 

There  can  be  no  longer  any  doubt  that  the  entire  l)rain  is  pene- 
trated through  and  through  with  lymph-spaces ;  that  it  is,  so  to  speak, 
drained;  and  that  these  spaces  more  or  less  directly  communicate 
with  the  lymph-spaces  about  the  surface  of  the  brain. 

The  presence  of  the  lymphatic  spaces  about  the  ganglion-cells  as 
well  as  around  the  vessels  (perivascular  or  adventitial  spaces  between 
the  adventitia  and  media)  is  demonstrated.  The  emptying  of  these 
spaces  takes  place  through  the  veins  and  the  lymph-channels  running 
in  the  pia  mater  which  empty  into  the  deep  cervical  glands  and  the 
lymphatic  jugular  tracts.  The  epicerebral  lymph-spaces  that  have 
been  found  are  a  subdural  space  on  the  inner  surface  of  the  dura, 
between  this  and  the  outer  endothelial  layer  of  the  arachnoid,  and  the 
arachnoid  space,  between  the  arachnoid  and  pia. 

The  subdural  space  has  only  the  significance  of  a  capillary  space ; 
by  means  of  the  Pacchionian  granulations  (appendices  of  the  venous 
sinuses)  it  commimicates  with  the  sinuses  and  veins  of  the  diploe. 
The  arachnoid  space  is  a  sac  filled  with  lymph,  provided  with  a  mesh- 
work  formed  by  the  junction  of  the  arachnoid  and  pia  by  means  of  a 
loose  network.  Only  at  the  base  of  the  brain  are  these  meshes  large 
enough  to  form  cysts  ("cisterns").      (Key  and  Eetzius.) 

The  arachnoid  space  communicates  with  the  ventricles  and  the 
nerve-sheaths  of  the  optic  and  acoustic  nerves  (thus  with  the  perilym- 
phatic fluid  of  the  labyrinth).  The  subdural  and  arachnoid  spaces  do 
not  directly  connect  with  each  other.  However,  in  case  of  great 
increase  of  pressure  the  subarachnoid  serum  passes  by  filtration  into 
the  subdural  space  and  from  there  to  the  sinuses  and  veins. 


CHAPTER  III. 
Physiologic  Preliminaries. 

The  cerebral  cortex,  as  mentioned  in  the  foregoing  chapter,  is 
distinguished  histologically  by  its  great  wealth  of  ganglion-cells. 
Since  in  every  place  where  special  functions  have  their  seat  in  the 
central  nervous  system  a  collection  of  gray  matter  rich  in  ganglion- 


8  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

cells  i&  found,  the  gray  cortex  lias  long  been  the  subject  of  investiga- 
tion and  speculation.  Until  lately  the  idea  was  entertained  that  ihe 
various  portions  of  the  cortex  were  functionally  of  like  power  and 
importance  and  capable  of  acting  one  for  anotlier. 

Broca^s  proof  of  the  localization  of  the  faculty  of  speech  in  a 
limited  portion  of  the  cerebral  cortex  did  not  agi-ee  with  this  opinion 
as  defined  by  Flourens,  Vulpian,  Schiff,  and  others.  But  morphologic 
differences  of  its  stnicture  also  pointed  to  a  regional  differentiation  of 
its  functional  activity. 

In  1874  Betz  found  remarkably  large  ganglion-cells  (giant  cells) 
in  the  forebrain,  and  small  ones,  like  those  of  the  posterior  horns  of  the 
cord,  in  the  cortex  of  the  parietal  and  occipital  lobes,  the  difference 
being  analogous  with  the  anatomic  differentiation  of  the  cells  of  the 
anterior  and  posterior  horns  of  the  spinal  cord,  which  are  certainly 
physiologically  different.  Moreover,  Betz's  giant  cells  are  found  only 
very  sparingly  in  the  brains  of  children,  and  they  are  developed  only 
gradually  in  the  course  of  the  development  of  the  brain.  Further,  it 
is  interesting  to  note  Soltmann's  discovery,  that  the  cortical  regions 
where  these  cells  are  found,  in  very  young  animals  are  insensitive  to 
experimental  excitation,  and  only  later  can  be  excited  in  their  specific 
functions.  Finally,  the  fact  that  the  paths  of  voluntary  muscle- 
innervation  have  their  starting-point  in  the  frontal  lobes,  and  the 
sensory  paths  their  termination  exclusively  in  the  occipital  lobes  and 
the  neighboring  regions  of  the  parietal  lobes,  speaks  for  a  functional 
differentiation  of  the  cerebral  cortex. 

The  epoch-making  experimental  investigations  on  animals  of 
Fritsch,  Hitzig,  Ferrier,  Munk,  and  others,  with  which  numerous 
pathologic  findings  on  the  human  brain  harmonize,  must  be  thanked 
for  the  fact  that  to-day  we  are,  in  a  measure,  acquainted  with  the 
functions  of  the  cerebral  cortex  and  their  regional  arrangement.  It 
cannot  be  denied,  however,  that,  owing  to  the  fact  that  there  are 
fundamental  differences  of  form  and  function  between  the  brains  of 
animals  and  man,  the  results  of  experiments  in  cerebral  physiology 
cannot  be  immediately  applied  to  the  pathology  of  the  human  brain, 
but  must  be  taken  cum  grano  sails. 

Nevertheless,  the  results  of  circumscribed  stimulation  or  destruc- 
tion of  the  cortex  in  the  higher  animals  (dog,  ape),  brought  into  com- 
parison with  cases  of  strictly  localized  lesions  of  the  human  brain, 
must  be  regarded  as  giving  the  foundation  for  a  physiology  of  the 
cerebral  cortex.  The  investigations  of  ]\Iunk  are  remarkable  for 
completeness  of  technique  and  distinctness  of  interpretation  of  the 
experimental  results,  and  may  here  be  shortly  summarized. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  9 

The  Motor  Eegions  of  the  CoinvEX. 

As  was  shown  by  Fritsch  and  Hitzig,  and  Terrier,  stimulation 
(electric)  of  the  region  of  the  fissure  of  Eolando  (gyrus  centralis  an- 
terior and  posterior,  lobus  paracentralis,  and  the  bordering  portions  of 
the  prsecuneus)  induces  movements  of  certain  groups  of  muscles. 
Thus,  stimulation  of  the  lower  third  of  the  central  convolutions  causes 
contraction  of  the  muscles  of  the  region  supplied  by  the  facial  and 
hypoglossal  nerves;  of  the  middle  third,  contraction  of  the  muscles 
of  the  arm;  of  the  upper  third  and  median  surface,  contraction  of 
the  foot-muscles. 

Stronger  stimulation  of  the  motor  regions  of  the  cortex  causes 
convulsions  in  the  corresponding  groups  of  muscles,  and  even  general 
convulsions  (probably  explainable  from  radiation  of  the  irritation). 
Destruction  of  any  of  these  territories  causes  the  loss  of  volun- 
tary movement  in  the  corresponding  muscular  groups,  while  the 
associated  and  reflex  movements  may  be  retained,  though  then  the 
associated  movements  are  awkward. 

In  poisoning  by  ether,  chloral,  or  chloroform  these  regions  lose 
their  sensibility  to  stimuli.  From  these  facts  these  regions  have 
come  to  be  regarded  as  the  centers  of  voluntary  innervation,  as  the 
point  of  departure  of  the  will,  as  the  psychomotor  centers.  With 
paralysis,  however,  there  coexists  a  sensory  loss,  the  loss  of  conscious- 
ness of  the  position  of  the  limbs  involved.  The  same  results  have 
been  repeatedly  observed  in  cortical  paralysis  in  man. 

When  it  is  remembered  that  there  are  no  facts  to  prove  that  the 
cerebral  cortex  has  other  psychic  function  than  sensibility  (Meynert), 
perception,  and  reproduced  impressions  of  earlier  perception,  in  a 
wider  sense,  it  lies  near  to  refer  the  motor  loss  to  the  sensory  loss,  and 
thus  explain  it. 

The  theory  of  voluntary  movements  and  the  explanation  of  their 
initiation  or  loss  are  set  forth  by  Munk  as  follows: — 

The  cause  of  so-called  voluntary  movements  are  motor  ideas 
(residua,  memory-pictures  of  earlier  motor  acts,  according  to  Mey- 
nert, originally  arising  from  the  sensations  of  innervation  involved  in 
reflex  movements  arising  in  the  subcortical  centers — probably  in  the 
thalamus) .  The  occurrence  of  these  ideas  of  movement  with  sufficient 
intensity  or  clearness  induces  the  corresponding  (voluntary)  move- 
ment, provided  inhibition  is  not  in  play. 

The  loss  of  voluntary  (acquired)  movements  after  extirpation  of 
certain  portions  of  the  cerebral  cortex  is  explainable,  according 
to  Munk,  by  the  loss  of  the  corresponding  sensory  and  motor  con- 


10  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

cepts  (mental  paralysis:   i.e.,  mental  insensitiveness,  "mental  immo- 

büity'O- 

In  fact,  the  investigator  mentioned  ofl'ers  proof  that  the  so-called 
motor  centers  of  the  cortex  are  centers  for  sensation  (touch,  pressure, 
and  muscle  senses  for  the  corresponding  localities)  and  the  motor  and 
tactile  concepts  arising  from  the  sensations.  He  further  proves  that 
extirpation  of  the  cortical  regions  under  consideration  always  leads  to 
loss  of  the  corresponding  concepts,  and  extensive  destruction  to  lasting 
loss  of  all  sensations  and  sensory  concepts  (cortical  paralysis,  cortical 
immobility,  and  insensibility). 

According  to  this  theory,  in  case  of  loss  of  voluntary  movement 
after  extirpation  of  the  so-called  motor  regions  of  the  cortex,  there  is 
a  loss  of  memory-pictures  of  earlier  movements,  and  these  regions  are 
thus  considered  to  be  really  sensory.  The  awkward  performance  of 
associated  movements  which  may  be  still  retained  is  explained  by  the 
loss  of  the  controlling  and  regulating  concepts  of  muscular  and  tactile 
sensibility. 

The  paths  by  which  the  voluntary  innervation  from  the  centers 
is  conducted  to  the  muscles  run  from  the  corresponding  centers  of 
the  cortex  through  the  medullary  substance,  probably  having  no  con- 
nectioji  with  the  basal  ganglia;  pass  through  the  anterior  two-thirds 
of  the  posterior  limb  of  the  internal  capsule  to  the  middle  third 
of  the  crus ;  descend  to  the  pyramids  (in  the  pons  possibly  interrupted 
by  groups  of  ganglion-cells)  ;  decussate  with  the  corresponding  fibers 
of  the  opposite  half  of  the  cerebrum;  run  almost  exclusively  in  the 
lateral  columns  of  the  spinal  cord ;  penetrate  the  gray  substance  of  the 
anterior  horn  and  pass  outward  to  the  muscles  through  the  anterior 
nerve-roots.  The  paths  for  involuntary  innervation  (reflex  paths) 
pass  from  the  cortical  regions  to  the  optic  thalami  and  corpora  quad- 
rigemina,  traverse  the  tegmentum,  take  no  part  in  the  decussation  of 
the  pyramids,  and  pass  on  to  the  columns  of  Türck  in  the  spinal  cord, 
which  they  leave  by  the  anterior  nerve-roots. 

The  path  for  the  sensory  nerves  of  the  trunk  and  extremities  runs, 
after  these  nerves  have  passed  to  the  cord  through  the  posterior  nerve- 
roots,  in  the  posterior  (lateral)  columns  and  posterior  horns  of  the 
spinal  cord,  and  undergo  decussation  (as  Brown-Sequard's  unilateral 
lesion  proves)  soon  after  entering  the  cord.  Higher  up  the  sensory 
path  lies  in  the  funiculi  gracilis  and  cuneatus,  and  then  in  the  teg- 
mentum (separated  from  the  crura  by  the  substantia  nigra).  From 
here  it  passes  onward  through  the  posterior  third  of  the  posterior  limb 
of  the  internal  capsule,  joined  there  by_  the  collected  paths  of  the 
nerves  of  the  higher  senses  and  the  sensory  portion  of  the  trigeminus 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  '       H 

(" carrefour  sensitif" ),  and  through  the  medullary  substance  it  attains 
the  cortex  of  the  parietal  lobe.^ 

The  Cortical  Regions  of  Perception. 

Munk's  Visual  Area. — After  Panizza  (185G)  had  reached  tlie 
conclusion,  after  destruction  of  portions  of  the  cerebral  cortex,  and 
after  the  discovery  of  secondary  atrophy  of  the  same  parts  following 
enucleation  of  the  eyeball  in  dogs,  that  the  center  for  visual  percep- 


^  The  statements  in  the  last  two  pai'agraphs  are  not  in  accord  with  tlic 
results  of  recent  studies  of  the  anatomy  of  the  nervous  system. 

The  pyramidal  tracts  are  not  interrupted  in  the  pons ;  the  central  neuron 
ends  by  communicating  with  the  motor  cells  of  the  anterior  horn  of  the  spinal 
cord  of  the  opposite  side,  or  the  corresponding  motor  center  situated  at  a 
higher  level  in  the  brain  stem. 

There  is  no  definite  knowledge  of  "paths  for  involuntary  innervation 
(reflex)"  that  pass  doAvnward  through  the  basal  ganglia;  the  column  of 
Tiirck  is  but  a  part  of  the  motor  path  that  crosses  the  median  line  at  lower 
levels  than  the  pyramidal  decussation. 

The  uncrossed  motor  path  is  made  up  of  motor  fibers  that  pass  down- 
ward from  the  cortex  to  the  cord  and  have  the  same  destination  as  crossed 
fibers  from  the  opposite  hemisphere,  joining  these  fibers  after  the  decussation 
and  passing  downward  in  the  cord  in  the  lateral  pyramidal  tract  (homologous 
fibers). 

Unilateral  lesions  of  the  cord  (Brown-Sequard)  seemed  to  prove  the 
immediate  decussation  of  the  centripetal  sensory  conducting  path,  soon  after 
its  entrance  into  the  cord  from  the  posterior  spinal  roots.  But  closer  study 
of  the  actual  condition  present  in  unilateral  lesions  of  the  cord  shows  that  the 
assumption  of  immediate  crossing  of  the  sensory  fibers  is  not  justified,  and 
that  other  anatomic  relations  must  be  sought  to  explain  the  symptoms 
actually  present. 

The  fibers  of  the  sensory  paths  are  very  complicated.  They  are  all  prob- 
ably made  up  of  more  than  two  neurons,  and  all  undergo  more  or  less  com- 
plete decussation. 

Those  from  the  body  (serving  general  sensibility)  are  probably  all  in- 
terrupted in  the  optic  thalami,  whence  they  pass,  not  by  the  "carrefour 
sensitif"  (the  posterior  extremity  of  the  posterior  limb  of  the  internal  cap- 
sule), but  interspersed  with  the  motor  fibers  in  the  anterior  portions  of  the 
posterior  limb  of  the  capsule,  to  terminate  in  the  motor  area  of  the  cortex. 
The  "carrefour  sensitif"  is  probably  largely  made  up  of  fibers  serving  the 
higher  senses. 

The  lesions  of  the  "carrefour  sensitif,"  which  were  assumed  to  cause 
opposite  hemianesthesia,  were  probably  misinterpreted  by  Charcot;  for  later 
studies  have  shown  this  symptom,  when  isolated,  to  depend  upon  lesion  of  the 
optic  thalamus. 

The  central  gray  matter  of  the  spinal  cord  is  now  quite  generally  con- 
sidered the  most  important  structure  concerned  in  the  centripetal  conduction 
of  impulses  that  give  rise  to  "general  sensibility." — Translator. 


12  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

tiou  lay  iu  lliu  rcgiuu  oi  ihe  posterior  convolutions  of  the  cerebrum, 
and  after  Ferrier  had  proved  the  visual  center  to  be  in  tlie  occipital 
lobe,  Munk  recognized  and  demonstrated  this  region  to  be  the  seat 
of  visual  memor3^-pictures,  and  proved  that  destruction  of  tlie  occip- 
ital lobe  near  its  posterior  superior  extremity  produced  (mental) 
blindness  to  impressions  falling  on  the  eye  of  the  opposite  side.  The 
animals  could  see,  but  no  memory-concept  was  connected  witli  tlie  act 
of  vision.  The  animals  drew  no  conclusion  from  the  optic  pictures 
presented  to  them,  because  they  were  unintelligible.  They  were 
transferred  to  their  earliest  period  of  life,  since  the  memory-pictures 
which  actual  visual  images  had  left  behind  as  residua  were  wanting, 
owing  to  the  loss  of  the  ganglion-cell  groups  which  preserve  them  or 
which  possess  the  power  to  reproduce  them.  The  visual  image  thus 
seemed  an  entirely  new  and  unknown  perception,  and  the  creation  of 
new  memory-pictures  was  necessary,  which,  at  least  in  dogs,  when 
there  has  not  been  too  great  destruction  of  the  cortical  visual  center, 
is  possible. 

The  optic  tracts  imdergo  but  partial  decussation  in  the  chiasm, 
the  crossing  being  confined  to  the  internal  fibers.  The  visual  path 
passes  through  the  optic  nerves  to  the  corpora  geniculata,  and  then 
through  the  medullary  substance  to  the  lateral  surface  of  the  occipital 
lobe.  Whether  fibers  of  the  optic  tract  which  actually  pass  into  the 
external  corpora  geniculata  as  well  as  into  the  optic  thalamus  and 
corpora  striata  suffer  interruption  there,  is  yet  uncertain. 

By  experimentation  on  animals  it  is  shown  that  limited  destruc- 
tion of  the  visual  region  of  both  occipital  lobes  causes  psychic  blind- 
ness; extensive  destruction  of  the  same,  cortical  blindness.  Unilat- 
eral lesion  of  the  occipital  regions  causes  functional  loss  (hemianopsia) 
on  the  same  side  of  each  retina;  thus,  with  destruction  of  the  right 
occipital  cortex,  loss  of  function  of  the  right  half  of  each  retina.  The 
same  results  must  follow  destruction  of  the  optic  path  in  the  brain  or 
of  the  right  optic  tract.^ 

Kegion  of  Hearing  and  Speech  Center. — Ferrier  sought  and 
found  the  center  of  hearing  in  the  temporal  lobe.  Munk  demonstrated 
that  this  center  has  its  seat  in  the  neighborhood  of  the  lower  extremdty 
of  the  temporal  lobe  (gyrus  temporalis  superioris  et  medius),  since 
destruction  of  these  parts  of  the  cortex  causes  psychic  deafness.  Ani- 
mals thus   injured  still  hear,  but  they   do   not  understand   sounds. 


^  The  cortical  center  for  sight  is  the  cuneus;  the  visual  center  for  written 
language  is  unilateral  and  lies,  ordinarily, — in  right-handed  persons, — in  the 
left  angnlar  gyrus,  the  "pli  coiirbe"  of  French  writers. — Translator. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  13 

Analogous  results  have  been  observed  in  man,  where,  with  destruction 
of  the  point  of  the  temporal  lobe,  the  subjects  were  not  deprived  of 
the  ability  to  hear,  but  they  were  no  longer  able  to  understand 
sounds.  The  earlier  well-known  language  was  no  longer  intelligible 
to  them.^ 

The  auditory  path  runs  upward  from  the  aurlitory  ganglia  of 
the  medulla  through  the  pons  (?).  Its  fibers  soon  decussate,  then 
pass  into  the  upper  part  of  the  tegmentum  to  the  sensory  path 
(carrefour  sensiiif)  and  ouAvard  from  there  to  the  extremity  of  the 
temporal  lobe. 

The  fibers  which  pass  from  the  auditory  centers  in  the  fourth 
ventricle  to  the  cerebellum  are  probably  the  auditory  fibers  which 
come  from  the  labj^rinth,  and  probably  assist  in  the  function  of 
equilibrium,  which  is  ascribed  to  the  cerebellum. 

Since  the  decussation  of  the  auditory  paths  is  complete,  destruc- 
tion of  one  auditory  cortical  center  causes  (cortical)  deafiiess  on  the 
opposite  side.  The  auditory  center  is  the  sensory  center  for  speech, 
and  its  destruction  before  speech  concepts  have  been  developed  prevents 
their  development.  Lying  near  the  sensory  center  of  hearing  and 
standing  in  very  close  anatomic  and  functional  relation  with  it  is  the 
region  for  ideas  of  speech  movements.  This  motor  speech  center  was 
shown  by  Broca  to  be  in  the  third  frontal  convolution  (in  right- 
handed  persons)  of  the  left  hemisphere.  Destruction  of  this  region 
causes  loss  of  the  concepts  of  movements  necessary  for  the  production 
of  speech   (motor  and  ataxic  asphasia). 

Centers  of  Taste,  Smell,  and  General  Sensibility. — As  the 
center  for  the  sense  of  taste,  the  path  for  which  probably  runs  exclu- 
sively in  the  trigeminus  (Gowers),  Ferrier  distinguishes  the  uncinate 
gyrus.  Munk's  investigations,  at  least  in  dogs  and  monkeys,  speak  in 
favor  of  its  localizations  in  small  areas  of  the  base  in  front  of  the 
Sylvian  fissure.  Ferrier  gives  as  the  center  of  olfactory  perceptions 
and  ideas  the  uncinate  gyrus,  which,  especially  in  animals  dis- 
tinguished for  extraordinary  development  of  this  sense  (dogs,  cats), 
is  especially  well  developed.  Munk  presumes  that  the  cortex  of  the 
gyrus  hippocampi  contains  the  olfactory  center,  since  anatomic  con- 
nections lend  color  to  the  belief,  and,  in  one  case  of  a  dog  with  loss  of 
hoth  falciform  gyri,  there  was  complete  loss  of  the  sense  of  smell. 


^The  auditory  center  for  language  lies  in  the  superior  temporal  gyrus, 
and  is,  as  in  the  ease  of  the  center  for  wi'itten  language,  unilateral  (usually 
on  the  left  side),  and  in  a  way  independent  of  the  general  auditory  center;  for 
destruction  of  it  does  not  cause  deafness,  but  loss  of  power  to  comprehend 
speech. — Tbanslatok. 


14  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

Zuckerkandl  ("Ueber  das  Riechcentrum,"  1887),  from  studios  in  com- 
parative anatomy,  attributes  the  olfactory  center  to  Amnion's  horn. 
Ferrier  places  the  center  for  sexual  concepts  near  the  center  of  smell. 
Owing  to  the  intimacy  of  functional  relation  in  which  the  sexual  and 
olfactory  senses  stand  both  in  man  and  animals,  there  is  much  to  sup- 
port this  assumption.  The  center  for  general  sensibility  (posterior 
lobes)  is  still  undetermined.^ 

It  cannot  be  doubted  that  the  brain-cortex  also  influences  the 
vasomotor,  thermic,  and  secretory  functions.  Concerning  the  pos- 
sible centers  and  tracts  for  these  functions,  and  -whether  the  cerebral 
cortex  exerts  its  influence  directly  or  indirectly,  there  are  as  yet 
nothing  more  than  hypotheses. 

The  foregoing  facts  of  modern  experimental  physiology  make  it 
seem  certain  that  perception  and  movement  are  dependent  upon  certain 
definite  areas  of  the  cerebral  cortex. 

The  residua  (memory-joictures)  of  earlier  perceptions  and  move- 
ments are  the  elements  on  which  the  development  of  psychic  life  rests. 

The  conditions  for  this  development  are  that  the  memory-pictures 
which  multiply  in  the  various  areas  of  perception  be  associated;  that 
general  concepts  be  formed  from  them  which  contain  the  characteris- 
tics of  different  perceptions  in  the  same  sensory  sphere,  as  well  as  those 
of  other  sensory  areas. 

For  this  it  is  necessary  that  the  various  cortical  areas  be  in  ana- 
tomic connection  (through  "association-fibers,"  Meynert)  and  enter 
into  functional  relation. 

There  is  greater  possibility  of  this  when  the  centers  concerned  arc 
near  to  one  another  (olfactory-gustatory  sense,  olfactorj'-sexual  sense, 
motor  and  sensory  centers  of  speech,  muscular  sense  and  muscular 
movement) . 

The  complicated  muscular  actions  and  perfection  of  movements 
depend  on  the  associative  and  repeated  use  of  special  paths  of  connec- 
tion (association) .  By  far  the  most  important  element  in  the  develop- 
ment of  psychic  life  is  the  acquirement  of  speech — of  the  products  of 
the  thought  of  an  infinitely  long  mental  activity  of  an  entire  people,  of 
a  word  as  a  sign  for  a  condensed  thought,  comprehending  complete 
series  of  single  concepts.  A  further  important  associative  union  is 
that  of  tactile,  sensory,  and  visual  percepts  as  the  foundation  of  a 
general  concept  of  an  individual  body  and  the  consciousness  of  a  per- 
sonality (ego)  developed  out  of  it.  Therefrom  results  the  limitation 
of  the  individual  from  the  external  world,  of  which  the  dimensions 


'■Vide  note  on  page  II. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  15 

of  space  reach  consciousness  through  the  associative  co-oporation  of 
the  centers  for  the  movement  of  the  ocular  muscles  with  the  visual 
sphere,  and  the  resulting  development  of  concepts  of  space.  It  is 
remarkable  with  what  ease  these  associative  unions  are  established  in 
the  brains  of  the  young,  while  to  the  brain  of  a  mature  man  the 
acquirement  of  technical  manipulations,  the  mastery  of  a  foreign 
tongue,  are  exceedingly  difficult. 

The  paths  of  association  and  their  possibilities  of  combination  and 
application  are  innumerable.  The  better  the  constitution  of  the  cen- 
ters and  paths  is,  and  the  earlier  these  associative  combinations  and 
exercises  take  place,  the  more  richly  elaborated  will  be  the  content  of 
the  psychic  life  of  the  individual. 

From  these  facts  the  conclusion  is  drawn  that  intelligence  can 
only  be  conceived  as  the  combination  and  result  of  all  the  concepts 
arising  from  the  perceptions  of  the  senses  (Munk). 

It  is  therefore  quite  as  irrational  to  regard  intellect,  emotion,  and 
will  as  distinct  mental  faculties,  as  to  seek  for  their  localization  in 
anything  like  a  phrenologic  sense,  since  psychic  existence  is  one  and 
indivisible. 

How  physical  impressions  are  able  to  produce  psychic  activities 
in  the  ganglion-cells  of  the  cerebral  cortex,  considered  as  the  formal 
elements  and  substrata  of  psychic  actions,  eludes  the  powers  of  experi- 
mental science.  The  remotest  possible  material  foundations  of 
psychic  life  are  molecular  movements  in  the  ganglion-cells.  The  high 
power  of  activity,  both  in  intensity  and  quality,  of  the  cerebral  cortex 
is  made  possible,  on  the  one  hand,  by  its  abundant  supply  of  blood, 
and  the  readiness  of  its  distribution;  on  the  other,  by  its  abundance 
of  fatty  substances  (cerebrin,  lecithin,  etc.)  rich  in  carbon  and  hydro- 
gen, of  highly  complicated  chemic  constitution,  by  virtue  of  which  a 
higher  value  for  oxidation  and  a  remarkable  capability  of  dissociation 
are  attained. 

These  substances  are  apparently  formed  in  the  nerve-elements 
from  the  blood  and  rapidly  broken  up,  thus  liberating  a  great  amount 
of  working  power  or  living  force.  Moreover,  the  brain  undergoes  a 
periodic  cessation  of  activity— -i.e.,  psychic — in  sleep. 

Pflüger  and  AVundt  have  advanced  some  very  interesting  theories 
concerning  the  transformation  of  physico-chemic  action  into  psychic 
working  force  in  the  ganglion-cells. 


16  INTKODULTION  TO  THE  STUDY  OF  PSYCHIATRY. 

CHAPTER  IV. 
Psychologic  Preliminaries. 

All  psychic  life  consists  of  concepts  and  tlicir  action  and  reac- 
tion on  one  another.  All  the  functional  manifestations  of  mental 
life,  elementary  and  complicated,  find  their  common  association  in 
self-consciousness  (ego).  Consciousness  is  made  up  of  all  the  con- 
cepts present  in  tlie  knowing  ego  during  a  unit  of  time.  All  that  is  not 
immediately  present  in  consciousness  is  latent  virtual  concept.  All 
concepts  arise  primarily  from  sense-impression,  and  owe  to  them  their 
repeated  re-excitation.  Sensations  are  elementary  concepts.  They 
possess  intensity  and  quality.  The  former  is  dependent  on  the  irrita- 
bility of  the  feeling  organism  (measured  by  the  exact  minimum  of 
irritation  that  can  be  felt — threshold  of  irritability) ;  the  irritability 
is  a  variable  quantity,  depending  on  the  state  of  excitability  of  the 
peripheral  organs  of  sense,  the  sensory  centers  of  the  cerebral  cortex 
(attention,  sleep,  waking  state),  and  the  simultaneous  influence  of 
other  stimuli. 

It  varies,  too,  for  the  different  spheres  of  sense  and  may  be 
psycho-physically  measured. 

The  quality  of  a  sensation  is  dependent  upon  the  kind  and  form 
of  the  movement  (number  and  length  of  the  motor  waves)  which  lies 
at  the  basis  of  the  stimulus.  The  various  sensory  mechanisms  by 
virtue  of  their  anatomico-physiologic  arrangement  respond  with  sen- 
sation only  to  waves  of  motion  the  rapidity  of  which  lies  within  certain 
definite  limits. 

Out  of  the  infinite  number  of  single  sensations,  by  the  fusion  of 
like  and  the  differentiation  of  unlike  percepts,  sensory  concepts  are 
gradually  formed  which  unite  with  one  another,  become  separated 
from  their  original  sensory  source,  and  are  elaborated  into  general 
concepts,  ideas,  judgments,  and  conclusions. 

Fused  in  the  consciousness  of  the  unity  of  the  body,  they  finally 
become  a  complex  of  concepts  (ego),  which  distinguishes  itself  from 
the  external  world,  and  from  every  new-formed  concept. 

All  (sensory)  concepts  pass  through  consciousness  under  the 
aspect  of  time  and  space. 

Every  concept  that  has  once  been  present  in  consciousness  may 
be  reproduced  and  recognized  as  identical  with  the  original  concept 
(memory). 

The  reproduction  is  spontaneous  (pliysiologic  excitation),  or  it  is 
induced  directly  by  a  sense-impression  (apperception)  or  indirectly 
by  the  processes  of  association  consequent  on  a  perception. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  17 

The  more  frequently  and  clearly  an  original  concept  has  been 
present  in  consciousness,  and  especially  if  emphasized  by  an  emotion, 
the  greater  will  be  the  facility  of  its  reproduction.  The  reproduced 
concept  may  be  identical  with  the  original  or  altered  (imagina- 
tion). Imagination  never  creates  anything  absolutely  new,  but  only 
a  new  combination  of  the  old.  Its  formative  activity  is  partly  invol- 
untary and  partly  affected  by  the  will. 

The  reproduction  of  a  sensory  idea  is  accompanied  by  a  feeble 
sensory  excitation  (sensory  picture),  just  as  ideation,  constantly  sus- 
tained by  the  senses,  is  thus  excited  to  activity. 

Our  concrete  ideas  are  always  accompanied  by  certain  psychic 
movements  that  are  called  feelings.  Tliis  coloring  of  ideas  by  feelings 
is  a  fact  which  is  ascribed  to  the  affective  faculty.  The  nature  of  the 
coloring  (pleasure,  displeasure)  is  dependent  partly  on  the  content  of 
the  concrete  idea  and  its  intensity  and  duration  (stimuli  in  themselves 
pleasant  cause  unpleasant  feelings  when  too  strong  or  too  long  con- 
tinued), partly  on  the  nature  of  the  idea  (sensual,  abstract,  apper- 
ceptive, reproduced),  since  the  ideas  called  up  by  sensual  impressions 
(sense-perceptions,  common  sensations)  excite  feelings  of  special  in- 
tensity in  consciousness  (affective  faculty). 

Not  less  important  than  the  content  of  the  ideas  for  the  pro- 
duction of  feelings  are  the  nature  and  mode  of  the  formal  process  of 
thought. 

Slowed  or  inhibited  thought  (inability  to  comprehend  or  remem- 
ber a  fact)  induces  lively  feeling  of  displeasure,  and  the  same  is  true 
in  case  of  failure  of  change  of  ideas  {ennui,  melancholia),  while,  on 
the  other  hand,  facilitated  conception  (finding  the  solution  of  a 
problem,  the  recollection  of  a  name  that  had  been  forgotten),  rapid 
change  of  ideas  (diversions,  mania,  etc.),  induce  pleasurable  emotions. 
The  resultant  state  represented  by  all  the  emotions  at  once  present  in 
consciousness  constitutes  the  mood.  It  is  conditioned  by  the  content 
of  the  concrete  ideas,  by  the  nature  and  mode  of  the  formal  process 
of  thought,  and  by  the  state  of  general  feeling.  A  higher  grade  of 
emotional  reaction  to  ideas  which  convulses  consciousness  is  called 
an  affect. 

Its  conditions  lie  in  the  suddenness  of  the  causal  ideas,  their  con- 
tent, their  peculiar  significance  for  the  innermost  kernel  of  the  per- 
sonality (ego),  and  their  duration.  At  the  same  time  the  suscepti- 
bility of  the  thinking  subject  to  excitation  (which  is  again  conditioned 
by  earlier  impressions  and  the  habitual  tone  and  temperarnent)  is 
important. 


18  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

Emotions  may  be  induced  by  reproduced  ideas  as  well  as  by 
sense-perceptions.  The  ideas  induced  reflexly  by  unconscious  opera- 
tion of  the  psychic  organ  are  of  peculiar  importance  in  pathology 
(irritation  of  peripheral  organs,  as  in  hypochondria,  nutritive  dis- 
turbances of  the  psychic  organ  itself,  and  consciousness  of  inhibition 
of  its  functions). 

They  may  induce  lively  alTects,  even  where  the  idea  is  not  clearly 
defined  with  a  concrete  content. 

jMorcover,  in  the  production  of  affects,  the  formal  modalities  of 
activity  of  the  ideational  process  play  an  important  role.  The  most 
violent  affects  are  produced  by  disturbed  or  facilitated  activity  of 
ideas  (imperative  ideas). 

The  all'ect  is  especiall}'  violent  when  an  idea,  through  its  union 
with  a  strong  feeling,  induces  impulse  to  act,  and  this  state  of  tension 
does  not  find  immediate  relief  in  action.  Then  affects  of  anger  and 
fury  result;  while,  on  the  other  hand,  a  sudden  removal  of  tension 
(by  action)  induces  a  pleasurable  affect. 

We  differentiate  pleasant  and  unpleasant  affects  according  to  con- 
tent. 

The  affects  react  on  the  circulation,  muscle-tone,  and  the  vegeta- 
tive functions,  and  accompany  changes  of  these  functions.  This  holds 
true  of  the  affects  of  the  healthy  as  of  the  affective  states  of  the  insane 
(melancholia,  mania).  In  the  latter  conditions  certain  precordial 
sensations  (precordial  distress  and  precordial  sense  of  pleasure)  and 
secretory  (weeping)  and  motor  phenomena  (laughing,  etc.)  are  espe- 
cially worthy  of  attention. 

An  especially  important  form  in  which  emotions  and  affects  may 
occur  is  the  ethic.  Moral  feelings  (sentiments)  relate  exclusively  to 
the  personal it}^  whether  it  be  self  (selfishness)  or  another  (sympathy), 
and  they  arise  from  ideas  which  affect  the  innermost  kernel  of  the 
personality,  the  aggregate  of  ideas  forming  self-consciousness.  Sym- 
pathy represents  a  higher  grade  of  development  of  selfish  feelings. 
It  consists  of  the  transfer  of  our  own  selfish  feelings  to  another  per- 
sonality, and  our  feeling  with  it.  In  its  lower  grades  of  development 
sympathy  is  limited  in  its  manifestation  to  feeling  for  kin ;  but.  as  the 
fairest  flower  of  mental  culture,  it  extends  to  embrace  all  mankind. 
The  ascendency  of  altruistic  feeling  over  egotism  is  the  objoct  aimed 
at  in  the  cultivation  of  the  individual  and  the  race.  The  highest 
satisfaction  of  selfish  feeling  arises  from  the  fulfillment  of  this  end, 
which  is  the  object  of  all  moral  precepts.  Upon  subjective  recogni- 
tion of  this  conscience  depends;  on  the  objective,  morality.  It  be- 
comes a  law  when  declared  by  mankind  (society,  state)  to  be  a  binding 


THE  SUBJECT  AND  AIDS  IN  ITS  S^FTIDY.  19 

precept,  and  its  obedience  is  made  a  duty  of  the  individual.  Tlie 
ethic  feelings  and  affects,  like  affects  in  general,  are  essentially  mani- 
fested in  two  forms:  pleasurable  (self-esteem,  respect,  sympathy  in 
another's  happiness)  and  painful  (self -contempt,  contempt,  pity). 

When  we  turn  to  the  processes  of  thought  we  find  as  a  common 
characteristic  that  they  are  arranged  under  certain  general  categories 
of  space  and  time.  The  general  idea  of  space  results  primarily  from 
the  information  derived  from  the  tactile  and  muscular  senses;  the 
general  idea  of  time  depends  on  the  succession  of  ideas,  in  that  they 
pass  through  consciousness,  reciprocally  crowding  and  expelling  one 
another.  The  shortest  time  within  which  one  idea  follows  another  is 
psycho-physically  measurable,  and  it  is  found  to  average  one-eighth  of 
a  second.  The  one  idea  present  in  consciousness  draws  from  the 
infinite  number  of  latent  ideas,  lying  just  at  the  threshold  of  con- 
sciousness, single  ones,  and  is  extinguished  by  them.  This  process  is, 
for  the  most  part,  involuntary,  and  attention  and  will  are  able  only  in 
a  limited  degree  to  modify  the  procession  of  ideas. 

The  procession  of  ideas  is,  however,  not  without  laws.  Our 
abstract  thought  moves  in  the  form  of  judgments,  which  are  logically 
connected  in  the  form  of  speech  (sentence).  With  this  logical 
sequence  of  ideas  there  is  also  a  mechanical  sequence:  the  so-called 
association  of  ideas.  Ideas  may  call  each  other  into  consciousness 
mechanically,  thus :  from  the  relation  of  the  whole  to  a  part  (a  por- 
tion of  the  body  or  a  part  of  a  statue  calls  up  the  completing  idea  of  the 
whole  body  or  of  the  whole  statue)  ;  from  the  relation  of  cause  and 
effect  (hearing  the  report  of  a  gun  calls  up  the  idea  of  a  hunter) ; 
from  similarity  and  contrast  (a  physiognomy  which  excites  the  com- 
paring idea  of  similar  faces;  the  idea  of  heaven,  which  associates  itself, 
in  a  way,  with  the  opposite  idea  of  hell)  ;  associations  by  habit  (Our 
Father,  who  art  in  heaven)  ;  the  simultaneous  occurrence  of  ideas 
or  their  occurrence  under  like  circumstances  (reproduction  of  abso- 
lutely disparate  events  Mdiich  were  of  simultaneous  occurrence,  recol- 
lection of  persons  on  revisiting  the  locality  where  their  acquaintance 
was  made) ;  finally  from  phonetic  similarity  (pine,  mine ;  taper, 
paper).  Under  physiologic  conditions,  in  spite  of  all  energy  of  the 
will,  a  concrete  idea  remains  in  consciousness  but  a  short  time,  being 
blurred,  pushed  aside,  and  superseded  by  others;  under  pathologic 
conditions  (hindered  association  of  ideas)  it  may  remain  in  conscious- 
ness with  abnormal  intensity  and  duration  and  thus  induce  important 
disturbances  (imperative  idea). 

The  motor  side  of  mental  life,  corresponding  with  its  various 
stages  of  development,  offers  various  phenomena.     The  lowest  form 


20  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

of  uiovi'inent  is, reflex.  It  is  found  pre-established  in  tlie  anatomic 
arrangement  of  the  central  nervous  system  of  the  newborn.  This 
form  of  reflex  movement  takes  place  unconsciously.  The  excitants 
are  sensory  stimuli.  A  higher  form  of  movement,  but  one  standing 
very  near  to  simple  reflex  movement,  is  the  sensorimotor  resulting  from 
sense-impressions.  It  is  accomplished  at  the  threshold  of  conscious- 
ness. Instinctive,  impulsive  movement  stands  a  degree  higher.  Its 
motive  is  formed  by  organic  sensations.  It  represents  a  lower  stage 
of  consciousness.  Voluntary  action  is  a  completed  form  of  psycho- 
motor activity.  It  is  begun  and  completed  within  the  sphere  of  con- 
sciousness. Its  primary  cause  is  an  idea  colored  (accompanied)  by  a 
feeling  The  more  intense  this  feeling  is,  the  more  certain  is  a  desire 
to  result.  The  movement  undertaken  to  satisfy  a  desire  is  an  act. 
The  thing  desired  is  thus  conceived  of  as  attainable.  Otherwise  there 
is  simply  longing  or  wishing.  An  act  always  presupposes  ideas  as 
motives,  but  these  may  be  more  or  less  clearly  defined  in  consciousness. 
An  act  the  motive  of  which  is  not  clearly  present  in  consciousness  is 
impulsive.  Affective  acts  are  closely  related  to  impulsive  acts.  They 
arise  unconsciously  and  involuntarily,  but  the  will  is  able  in  a  certain 
degree  to  repress  them  (training). 

Conversely,  the  highest  degree  of  voluntary  action  is  that  known 
as  free  will.  Its  conditions  are  complete  consciousness  of  the  willing 
subject  of  the  complicated  ideas  of  utility  and  morality,  reflection  on 
the  various  possibilities  of  willing  or  not  willing  which  rest  on  those 
logical  and  moral  motives,  and  the  possibility  of  deciding  to  act  in 
accordance  with  them. 

For  the  attainment  of  a  certain  constancy  m  manner  of  action 
character  is  necessary;  that  is,  established  psychic  associations  fixed 
by  experience  and  education,  which  have  become  so  strengthened  that 
they  constitute  ideational  complexes  and  emotional  and  voluntary 
impulses.  In  the  child  these  conditions  are  not  present,  and  they  are 
often  destroyed  or  at  least  injured  by  mental  disease. 


CHAPTER  V. 


The  Special  Place  of  Mental  Disease  in  the  General  Domain  of 
Cerebral  Disease. 

From  all  that  has  gone  before,  there  can  be  no  doubt  that  tlie 
disturbances  of  psychic  functions  as  they  occur  in  insanity  are  the 
expression  of  changes  in  the  organ  that,  under  normal  conditions, 
makes  possible  the  occurrence  of  the  psychic  processes.    Thus,  the 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  21 

psychic  disease  proves  the  existence  of  a  disease  of  the  cerchral  cortex; 
and,  since  circumscribed  cortical  disease  (focal  lesions)  can  occasion 
only  symptoms  of  defect  referable  to  the  diseased  portion  of  the 
cortex,  the  psychic  abnormality  can  only  be  conditioned  by  a  diffuse 
change  in  the  cerebral  cortex. 

Psychic  diseases  arc  diffuse  diseases  of  the  cortex  of  the  brain. 

The  results  of  postmortem  examination  of  those  dying  insane  seem  at 
first  glance  to  opjDOse  this  statement,  since  in  the  majority  of  cases  macroscopic 
appearances  of  disease  are  wanting. 

However,  since  the  foregoing  sentence  is  the  logical  conclusion  from  the 
facts  of  experience,  one  may  presume  that  the  disturbances  of  nutrition  during 
life  (as  toxic  and  febrile  delii'ium  shows)  of  the  highly  sensitive  cortex  are  so 
fine  that  with  ordinary  instruments  they  are  not  demonstrable  postmortem. 

Like  many  other  diseases  of  the  central  nei-vous  system  without  demon- 
strable postmortem  lesions,  the  majority  of  psychic  diseases  seem  to  be  for 
that  reason  functional;  to  be  the  result  of  molecular  changes — a  disturbance 
of  nutrition. 

The  conception  of  many  psychoses  as  being  functional  diseases  must  not, 
however,  be  given  too  wide  an  application,  and  thus  encourage  neglect  of 
investigation  of  the  pathologico-anatomic  foundation  of  the  psychoses.  It  must 
not  be  forgotten  that  in  many  forms  of  mental  disease  pathologico-anatomic 
lesions  are  found  which  are  almost  identical;  that  it  is  but  a  short  time  since 
it  has  become  customary  to  examine  the  brain  otherwise  than  with  the  knife 
and  fork,  to  use  Griesinger's  excellent  expression;  further,  that  the  microscopic 
examination  of  the  brain  that  has  manifested  abnormality  of  its  functions  is 
seldom  without  profit;  and  that  our  knowledge  of  the  histologic  details  of  this 
most  complicated  of  organs,  and  especially  of  the  relation  of  the  neuroglia  to 
the  actual  nervous  tissue,  is  still  very  defective. 

We  remember,  too,  that  the  causes  of  the  clinical  phenomena  may  consist 
of  anomalies  of  innervation  of  the  vessels  and  the  anemia,  hyperemia,  edema, 
and  change  of  the  nonnal  relations  of  pressure  thus  induced,  which  death  com- 
pletely removes;  or  finally  in  chemic  changes,  when  the  normal  chemistry  of 
the  brain  is  incompletely  understood  and  the  pathologic  not  at  all. 

Experience  teaches  that  it  is  almost  exclusively  in  the  primary  forms,  the 
initial  stages,  of  insanity  that  we  find  no  postmortem  lesions,  and  we  are  forced 
to  the  assumption  of  anomalies  of  innervation,  in  the  distribution  of  blood  and 
chemic  pi'ocesses. 

On  the  other  hand,  in  the  secondary  and  final  stages  of  insanity  we  find, 
as  a  rule,  material  changes  consisting  in  part  of  the  residua  of  inflammatory 
and  degenerative  processes  affecting  the  membranes  and  cortex  which  were 
clearly  inaugurated  by  such  nutritive  disturbances. 

To-day  at  least  we  may  say  that  there  is  not  a  single  diffuse  alteration 
of  the  cortex  of  the  cerebrum — be  it  a  hyperemia,  anemia,  edema,  or  inflamma- 
tion— which  does  not  manifest  itself  clinically  by  a  disturbance  of  the  psychic 
functions.     (Griesinger.) 

Thus,  from  an  anatomic  standpoint,  mental  disease  may  be  de- 
fined as  a  diffuse  disease  of  the  cerebral  cortex  consisting  of  chang-es 


22  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

which  may  vary  from  mere  alterations  of  cortical  nutrition  to  gross 
changes  of  structure,  especially  inflammatory  and  degenerative  in 
character. 

In  this  treatise  the  disturbances  of  psychic  functions  which  occur 
as  symptoms  of  the  graver  disturbances  of  general  nutrition  (intoxi- 
cation, fever)  are  not  placed  in  the  category  of  psychic  diseases,  only 
such  mental  disturbances  being  considered  to  fall  within  the  term 
insanitj'  as  are  tlie  expression  of  spontaneous  processes,  arising  inde- 
pendently in  the  cerebral  cortex  and  having  in  general  a  chronic  and 
afebrile  course. 

This  distinction  is  practical,  but  arbitrary,  and  not  strictly  scientific,  since 
such  acute  and  symptomatic  nutritive  disturbances  of  the  cerebral  cortex  also 
become  independent,  and,  outlasting  the  primary  process,  develop  into  true 
psychoses.  Certain  it  is  that  there  are  easy  transitions  from  the  deliriums  of 
inanition,  intoxication,  and  fever  to  the  psychoses  (delusional  insanity).  On 
the  other  hand,  these  psychoses  may  occasionally  inin  their  courses  acutely, 
even  very  acutely.  Therefore  the  statement — mental  diseases  are  diffuse  dis- 
eases of  the  cortex  of  independent  character  and  generally  of  chronic  and 
afebrile  course — contains  only  a  relative  and  conventional  truth. 

Clinically  mental  diseases  (psychoses)  form  a  part  of  cerebral 
pathology.  The  study  of  the  etiology  of  psychic  diseases  teaches  this 
unequivocally,  in  that  the  laws  of  origin  of  mental  diseases  are  essen- 
tially the  same  as  those  of  other  diseases  of  the  brain  and  nerves, 
where  the  biologic  law  of  heredity,  which  can  be  conceived  only  as 
resting  on  an  organic  basis,  is  of  the  greatest  importance. 

Mental  diseases  are  often  inherited,  and,  at  the  same  time,  vari- 
ous cerebral  and  nervous  diseases  in  the  progenitors  may  induce  a  dis- 
position to  insanity  in  the  following  generation. 

With  this  exquisite  tendency  to  transmission  tliese  abnormal 
states  have  the  peculiarity  that  they  may  reappear  in  the  following 
generations  in  the  most  varied  forms  of  neuroses,  and  thus  etiologically 
the  most  widely  differing  cerebral  and  nervous  diseases  can  only  be 
regarded  as  members  of  one  and  the  same  pathologic  famil}'. 

No  less  frequently  do  we  see  in  an  individual  the  successive  transi- 
tions from  simple  neuroses  (chorea,  h3'steria,  epilepsy)  to  insanity;  or 
we  see  in  several  members  of  the  same  family  in  which  a  predisposition 
is  present  that  an  exciting  cause  like  fright  (according  to  accidental  or 
individual  circumstances)  induces  epilepsy  in  one,  insanity  in  an- 
other, etc. 

With  reference  to  the  clinical  synijitoinatology,  the  psychoses  may 
be  defined  as  a  special  class  of  ccreWral  diseasus,  distinguished  by  the 
predominance  of  disturbances  of  the  psychic  functions  in  the  disease- 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  23 

picture.  But  these  are  not  the  ouly  symptoms,  for,  owing  to  the  direct 
or  indirect  influence  of  the  cerebral  cortex  on  the  sensory,  sensorial, 
motor,  vasomotor,  secretory,  trophic,  and  heat-regulating  functions, 
there  may  be  corresponding  physical  symptoms  associated  with  those 
that  are  purely  mental. 

On  the  other  hand,  it  is  to  be  remembered  that  psychic  disturbances 
do  not  occur  exclusively  in  the  so-called  psychoses,  but  also,  at  least  in  an 
elementary  form,  in  all  the  cerebral  diseases.  Focal  diseases  of  the  cortex  and 
any  cerebral  disease  may,  owing  to  sympathetic  or  secondary  anatomic  effect 
upon  the  cortex,  begin  with  general  mental  disturbance,  which  may  be  either 
temporary  or  lasting,  though,  of  course,  in  focal  diseases  of  the  brain  motor 
and  sensory  distvirbances,  and  not  mental  symptoms,  occupy  the  foreground  of 
the  disease-picture. 

Thus  it  is  evident  that  the  separation  of  insanity  from  other  diseases  of 
the  brain  is  artificial  and  arbitrary,  and  justifiable  only  on  practical  grounds 
(social  importance,  wealth  of  symptoms,  imperfection  of  the  science,  pecul- 
iarity of  the  methods  of  its  study). 

Practically,  without  reference  to  their  peculiarity,  it  is  necessary  to 
study  and  treat  the  psychoses  as  we  do  other  diseases  of  the  brain. 

The  disturbances  of  psychic  functions  are,  it  is  true,  the  most  prominent, 
but  in  many  instances  they  fail  to  furnish  the  index  of  diagnosis  or  prognosis. 

Therefore  the  method  of  clinical  examination  must  not  be  exclusively 
psychologic,  but  cerebro-pathologic  in  the  comprehensive  sense,  with  special 
reference  to  the  symptoms  that  are  not  properly  psychic  and  their  employ- 
ment in  diagnosis  and  prognosis.  Owing  to  the  very  nature  of  these  specially 
characterized  diseases  of  the  brain  they  raise  questions  that  are  still  more  far 
reaching.  The  cerebral  cortex  as  the  organ  of  psychic  function  is  the  indis- 
pensable substrattun  of  that  which  we  call  psychologically  "ego"  and  "con- 
sciousness." 

A  diffuse  disease  of  the  cerebral  cortex  must  necessarily  induce 
a  change  of  consciousness  and  the  psychic  personality.  Hence  the 
psychosis  appears  not  simply  as  a  disease  of  the  brain,  but  also  as  an 
abnormal  alteration  of  the  personality. 

From  this  fact  arises  the  necessity  in  medico-practical  relations  of 
psychic  and  individualizing  treatment  of  the  abnormal  personality,  and  it  also 
entails  socially  and  legally  an  important  change  of  the  person's  relations  to 
law  and  society.  Thus  psychiatry  assumes  a  place  of  the  greatest  importance 
to  society. 

One  of  the  most  weighty  matters  connected  with  it  is  that  of  State  care 
for  the  ever-increasing  number  of  insane  in  all  lands  during  the  last  decades. 
The  appropriate  provision  for  these  patients,  their  cure,  and  their  humane 
care  in  case  of  incurability  are  the  subject  of  earnest  deliberation  on  the  part 
of  legislators  and  physicians,  especially  since  experience  teaches  that  closed 
asylums  do  not  suffice  for  the  care  of  all  these  patients,  and  many  of  them 
may  be  adequately  provided  and  cared  for  in  a  less  restricted  way  (families, 
colony  system),  the  value  of  which  technically  and  economically  must  be 
decided  in  the  future. 


24  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

This  much  is  certain:  closed  asylums  for  curable  and  dangerous  patients 
cannot  be  dispensed  with. 

Psychiatry  is  of  no  less  importance  in  its  medico-legal  relations. 

The  insane  are  legally  iiTCsponsible,  their  rights  of  citizenship  are  lost 
during  the  disease,  and  they  may  become  dangerous  to  society.  Thus  it  may 
be  necessary  to  deprive  them  of  freedom.  But  at  the  same  time,  since  they 
are  unable  to  care  for  themselves  and  manage  their  own  affairs,  tlu-y  require 
legal  protection.  From  these  circumstances  arises  a  series  of  legislative  ques- 
tions, partly  general  and  partly  concrete,  the  scientific  answers  to  which  de- 
pend immediately  upon  psychiatry  in  the  sense  of  legal  psychopathology: 
questions  which  are  of  the  greatest  importance  for  order  and  security  in  the 
State  and  for  the  honor,  life,  and  freedom  of  the  patients. 

Unquestionably  the  most  difficult  question  in  this  relation  is  that  raised 
concerning  the  mental  condition  of  a  man  at  the  time  of  the  commission  of  a 
crime.  Indeed,  many  problems  in  this  sphere  still  remain  for  solution;  the 
dividing-line  between  criminality  and  insanity  is  still  vague  and  uncertain. 
Nevertheless  psychiatry  may  approach  these  problems  with  confidence  if  it 
confine  itself  to  strictly  clinical  ground  and  avoid  all  phraseology  and,  where 
science  does  not  suffice,  says  fearlessly  "non  liquet." 


CHAPTER  VI. 


Importance  of  the  Study  of  Psychiatry. 

In  spite  of  its  incomplete  development  as  a  science,  psychiatry  in 
connection  with  the  other  sciences  has  a  significance  by  no  means 
small,  and  it  should  be  given  its  deserved  place  and  attention  in  the 
schools.  Inasmuch  as  it  undertakes  the  investigation  of  the  etiology 
of  insanit}^,  one  among  the  worst  of  social  evils,  it  forms  an  interesting 
part  of  hygiene,  the  problem  of  which  is  the  prevention  of  disease. 

Here  it  touches  the  domain  of  pedagogics,  since  not  infrequently 
mental  disease  is  the  result  of  a  faulty  education  which  did  not  take 
into  consideration  the  peculiarities  of  constitution  and  temperament. 
Should  the  science  of  pedagog}-  make  a  deeper  study  of  man  in  his 
normal  and  pathologic  relations,  many  of  the  faults  and  difficulties 
of  education  w-ould  disappear;  and  the  choice  of  many  inappropriate 
occupations  would  be  obviated,  and  many  minds  saved. 

In  its  relation  to  theology,  psychiatry  is  interesting  since  it  shows 
the  psychopathic  origin  of  numerous  religious  errors  and  sects;  and 
in  history^  it  shows  how  many  of  the  mysterious  acts  of  historic 
personages  find  their  true  explanation  in  psychopathic  conditions. 


^Bird,  Allgemeine  Zeitschrift  für  Psychiatrie,  V,  page  151  (Johanna  von 
CastUien),  page  569  (Charles  VI  of  France);  VI,  page  12  (Charles  IX  of 
France);  VII,  pages  45,  218;  VIII,  pages  17,  209  (various  historic  persons); 
Dietrich,  idem,  IX,  page  558  (Philip  V  und  Ferdinand  VI) ;   Bergrath,  idem,  X, 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  25 

Psychology  as  the  science  of  the  human  mind  may  find  important 
sources  of  knowledge  in  mental  pathology,  just  as  general  pathology  is 
of  the  greatest  significance  for  physiology.  Certainly  psychiatry  forms 
an  integral  part  of  knowledge  necessary  in  the  comprehensive  educa- 
tion required  by  the  zealous  student  of  nature  and  the  physician,  and 
it  is  indispensable  for  his  mental  and  moral  culture — certainly  a  most 
important  means  to  a  higher  philosophic  view  of  the  world.  Its  study 
bears  fruit  in  the  life  of  every  day,  since  it  promotes  a  proper  under- 
standing of  mentally  abnormal  persons,  so  many  of  whom  are  found 
wandering  about  in  society. 

Here  comes  the  question:  Why  does  the  general  practitioner 
need  a  knowledge  of  insanity  ? 

It  is  remarkable  that  in  countries  of  the  first  rank  in  civilization, 
like  Germany  and  Austro-Hungary,  the  State  requires  no  knowledge 
of  insanity  of  the  practicing  physician,  but  only  of  the  legal  expert. 
Psychiatry  is  not  a  subject  of  the  State  examination  in  these  countries. 

However,  if  the  State  does  not  exact  a  knowledge  of  psj^chiatry, 
the  public  does  suppose  it  to  be  a  part  of  the  practicing  physician's 
acquirements.  It  is  dishonest  on  his  part  to  pretend  to  have  what  he 
does  not  possess.  A  knowledge  of  psychiatry  can  never  be  obtained 
from  books. 

When  a  physician  without  training  in  the  study  of  insanity  under- 
takes the  care  of  an  insane  patient,  he  assumes  a  great  responsibility, 
and  endangers  the  most  important  interests  (health,  life,  honor, 
fortune)  of  his  client. 

The  following  reasons  why  the  practicing  physician  should  acquaint 
himself  with  mental  diseases,  even  though  the  State  does  not  enjoin  their 
study,  may  be  mentioned: — 

1.  Cases  of  insanity  occur  in  the  practice  of  every  physician,  since  mental 
disease  is  A^ery  frequent  (one  case  may  be  reckoned  to  every  two  hundred  of 
the  population)  and  in  modern  society  is  becoming  more  and  more  frequent. 

To  be  sure,  a  considerable  number  of  these  cases  falls  into  the  hands  of 
specialists  (asylum  physicians),  through  the  necessity  of  their  commitment  to 
an  asylum  for  the  insane.  But  these  comprise  only  about  one-third  of  the 
whole  number  of  the  insane  population,  the  remainder  of  which  falls  to  the 
share  of  general  practitioners.  Just  in  proportion  as  psychiatry  becomes  a 
part  of  the  general  practitioner's  knowledge  it  becomes  possible  to  carry  out 
a  more  perfect  treatment  of  acute  cases  outside  the  asylum  walls  in  privacy 
.or  in  the  ordinary  hospitals.  This  course  is  rich  in  results  for  the  physician 
and  especially  beneficial  to  the  public. 


pages  249,  366;  WinsloAV,  "Obsciu'e  Diseases  of  the  Brain,"  pages  101-106; 
Wiedmeister,  "Der  Cäsarenwahnsinn,"  1875;  Eibot,  "Die  Erblichkeit,  über- 
setzt von  Hotzen,"  1876,  page  116  (the  family  of  the  Borgias,  the  Bourbons, 
Catherine  de  Medici,  etc.). 


26  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

The  timely  recognition  of  danger  of  mental  disease  and  its  prevention 
will  always  naturally  fall  to  those  that  are  not  specialists.  The  knowledge  of 
the  nature  and  significance  of  insanity  is  needed,  moreover,  in  order  to  prevent 
the  graver  dangers  of  suieide  and  dangerous  impulsive  acts  of  llie  alienated 
person  against  the  lives  and  property  of  others. 

But  with  reference  to  the  patients  tliat  must  be  iscut  iv  an  asylum  the 
general   practitioner   has  duties  to  fullill. 

First,  he  must  know  at  what  moment  the  treatment  by  a  specialist  and 
the  appliances  of  an  asylum  become  necessary  to  the  patient,  just  as  every 
physician,  without  being  a  specialist  in  operative  ophthalmology,  must  be  able 
to  recognize  glaucoma,  for  example,  and  whether  and  at  what  time  the  patient 
needs  the  aid  of  a  specialist.  But  in  case  of  necessity,  the  physician  has 
not  merely  to  send  the  insane  patient  to  an  asylum;  he  must  testify  to 
(he  existence  of  the  disease,  prove  the  necessity  of  admission  to  such  an  insti- 
tution, and  more  than  all  determine  the  facts  concerning  tlie  inception  of  the 
disease,  and  thus  scicntificallj'  prepare  the  case  for  the  specialist  in  insanity. 

'J'lie  liistory  and  pathogenesis  are  the  foundations  on  which  correct  judg- 
ment antl  treatment  of  such  cases  rest.  The  patient  is,  as  a  rule,  too  much 
disturbed  to  give  a  correct  history  of  his  trouble,  and  the  malady  is  often  so 
far  advanced  that  the  asylum  physicians  would  be  unable  to  obtain  the  facts 
concerning  tlie  inception  and  development  of  the  disease,  without  the  help  of 
the  attending  pliysician.  A  good  preliminary  history  is  therefore  an  invalu- 
able beneiit  to  both  physician  and  patient.  Besides,  a  large  number  of  chronic 
cases  are  again  discliarged  from  the  asylums,  and  could  be  cared  for  outside 
such  institutions,  inasmuch  as  they  often  require  only  temporary  treatment. 

^Vlleu  the  general  practitioner  becomes  thoroughly  educated  in  psy- 
chiatry, the  burden  of  the  much  overfilled  asylums  will  be  lightened,  and  home 
treatment,  Avhich  would  mean  a  greater  amount  of  freedom  and  comfort  for  in- 
numerable patients,  will  be  possible. 

2.  The  law  courts  often  have  to  decide  legal  questions  concerning  the 
mental  condition  of  persons,  and  require  the  testimony  or  opinion  of  the 
pliysician.  No  physician  can  legally  escape  this  duty.  The  sad  part  a  phy- 
sician plays  in  court,  in  a  case  of  questionable  soundness  of  mind,  when  he  is 
ignorant  of  psychiatry,  and  how  his  opinions  must  excite  astonisliment,  can 
be  but  alluded  to  here.  A  physician  that  has  no  practical  knowledge  of 
])syrliiatry  can  only  figure  as  an  expert  as  a  matter  of  form.  These  are  the 
(I j reel,  advantages  to  the  general  practicing  physician  of  the  study  of 
psycliiatry. 

But  there  are  also  indirect  advantages:  — 

1.  The  physician,  otherwise  practical,  takes  little  notice  of  the  person- 
ality of  the  patient,  notwithstanding  the  fact  that  in  severe  bodily  disease 
the  pei'son  (psychic),  as  the  subject  of  the  disease-process,  also  sufi'ers  and 
requires  attention.  This  important  part  of  the  healing  art  (medical  homi- 
letics,  mental  or  moral  treatment)  naturally  falls  to  psychiatry  and  its  thera- 
peutics. The  training  of  observation  for  the  appreciation  of  the  mental  needs 
of  a  patient  and  the  acquisition  of  the  art  of  exercising  a  beneficial  mental 
effect  are  invaluable  advantages  derived  from  the  study  of  the  insane  patient. 

2.  A  great  many  of  the  so-called  neuroses  are  neuropsychoses:  i.e.,  the 
mind  is  simultaneously  affected.  The  psychic  share  of  the  symptom-complexes 
of  hysteria,  hypochondria,  neurasthenia,  etc.,  can  only  be  recognLzcd  through 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  27 

psychiatric  diagnosis,  and  it  is  only  with  the  aid  afTorded  by  a  careful  con- 
sideration of  the  necessities  of  moral  treatment  that  these  conditions  can  be 
buccessfnlly  treated. 

3.  Many  febrile  and  chronic  constitutional  diseases,  and  a  great  many  of 
the  focal  cerebral  diseases,  are  accompanied  by  elementary  psychic  disturb- 
ances. Without  a  knowledge  of  psychiatry,  it  is  impossible  properly,  prac- 
tically, and  scientifically  to  appreciate  these  important  anomalies.  To  this 
extent  psychiatry  forms  an  important  and  integral  part  of  the  general  pa- 
thology of  the  central  nervous  system. 


CHAPTER  VII. 
Difficulties  and  the  General  Principles  of  the  Study  of  Mental  Diseases. 

Etiology,  as  well  as  cliuical  observation,  places  psychiatry  in 
the  domain  of  cerebral  pathology,  and  demands  the  same  method  of 
observation  and  treatment,  with  the  abandonment  of  all  one-sided 
psychologic  or  nietaphysic  theories.  In  spite  of  this  inner  relation- 
ship, the  study  of  mental  diseases  is  surrounded  with  peculiar  diffi- 
culties. 

At  first  sight  they  seem  to  have  no  analogies  with  the  manifesta,- 
tions  of  disturbed  functions  of  other  centers  of  the  nervous  system; 
they  seem  to  be  processes  peculiar  to  themselves. 

The  customary  methods  of  pathologic  anatomy  fail  us,  because 
clinical  phenomena  and  postmortem  findings  can  but  seldom  be 
brought  into  accord ;  and  no  less  do  the  sure  and  ready  means  of  diag- 
nostic exploration  fail  us — with  auscultation  and  percussion,  with 
pathologic  chemistry,  we  can  make  not  the  slightest  beginning  in  the 
domain  of  psychopathology.  Here  we  have  to  deal,  for  the  most  part, 
with  phenomena  of  a  new  order — the  psychologic.  From  variations 
of  degree  of  consciousness,  disturbances  of  the  memory ;  from  quali- 
tatively and  quantitatively  abnormal  feelings,  ideas,  impulses,  etc., 
we  draw  conclusions  concerning  the  nature  and  degree  of  the  disease 
of  the  brain. 

The  peculiarity  of  the  processes  of  insanity  is  such  only  in  appear- 
ance. If  mental  diseases  are  in  reality  diseases  of  the  brain,  then, 
notwithstanding  the  peculiarity  of  their  symptoms  and  symptom- 
groups,  they  miist  all  follow  the  general  laws  of  the  physiology  and 
pathology  of  the  nervous  system.  The  laws  of  excitability  and  excite- 
ment, of  exhaustion  and  exhaustibility,  of  reflex  action,  of  vicarious 
action,  of  irradiation  and  conduction,  of  eccentric  projection,  of  excita- 
tion, etc.,  all  must  hold  good  for  these  qualities  of  function. 

This  assumption  is  confirmed  to  the  fullest  extent — everywhere 
we  meet  with  manifestations  of  facilitated  and  inhibited  reflex  excita- 


28  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

bility  and  transference;  the  laws  of  eccentric  manifestation  we  meet 
at  every  step  of  observation.  No  less  does  the  general  course  of  mental 
disease  correspond  with  that  of  the  other  neuroses — temporary  la- 
tency and  intermission,  exacerbation  and  remission  due  to  cumulation 
of  stimuli  and  exhaustion,  periodicity  in  the  recurrence  of  symptoms. 
The  peculiarities  of  the  psychopathic  phenomena,  which  are 
grounded  in  the  specific  physiologic  pre-eminence  of  the  organ  affected, 
are  brought  much  nearer  to  our  understanding,  and  thus  lose  the 
impression  of  strangeness,  if  we  attempt  to  bring  them  into  analogy 
with  other  better  known  manifestations  of  disturbed  nervous  func- 
tions, and  translate  them,  as  it  were,  into  common  speech. 

Thus,  in  a  measure,  we  are  justified  in  speaking  of  psychic  hyper- 
esthesia and  anesthesia;  of  psychic  spasm  and  paralysis;  of  lessened 
and  increased  resistance  to  conduction;  of  increased  and  diminished 
psychic  reflex  excitability.  But  there  is  still  another  important  source 
of  help  offered  us  in  the  fact  that  insanity  is  a  disease. 

Disease  is  life  under  abnormal  conditions;  disease  and  health  are 
not  unconditional  opposites.     Psychopathic  manifestations  thus  can- 
.not  be  fundamentally  different  from  those  of  physiologic  life;    they 
must  present  many  analogies  and  transitions. 

These  assumptions  are  abundantly  confirmed.  The  elements  of 
which  abnormal  mental  life  is  composed  are  the  same  elements  that 
make  up  the  state  of  health,  only  the  conditions  of  their  origin  are 
changed. 

The  conditions  necessary  for  the  activity  of  the  psychic  functions 
in  normal  mental  life  are  (with  normal  nutrition  of  the  organ  of 
psychic  activity)  external  impressions  (excitation  of  the  senses)  as 
well  as  an  adequate  manner  of  reaction  of  the  ps5-chic  organ  to  the 
external  excitation.  Thus  a  constant  correspondence  between  the 
phenomena  of  consciousness  and  external  impressions  is  maintained. 
The  brain  of  the  insane  patient  is  in  an  abnormal  condition ;  the  cere- 
bral cortex  is  the  seat  of  a  disease-process,  and  because  of  this  it  is 
thrown  into  activity  by  inner  stimuli  (excitation,  irritation).  His 
psychic  organ  acts  spontaneously,  and  therefore  not  entirely  in  obedi- 
ence to  events  of  the  outer  world  and  the  impressions  derived  from 
these — feelings,  perceptions,  ideas,  impulses,  etc.  Thus  the  patient  in 
his  inner  world  is  out  of  harmony  with  the  outer  world  (alienatio  men- 
tis) ;  but  the  content  of  these  abnormal  psychic  processes  excited  from 
within  is  essentially  congruent  with  that  induced  by  external  excita- 
tion. It  is  not  the  quality,  but  the  manner  of  origin,  of  this  which 
determines  its  nature.  The  inner  central  spontaneous  excitants  are 
disturbances  of  nutrition  in  the  cerebral  cortex  which  act  as  stimuli. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  20 

This  disturbance  of  nutrition  prcsurucs,  Ijcsides,  two  oilier  important 
anomalies  in  tlie  cerebral  cortex:  changed  relations  in  tlie  reaction  to 
stimuli  coming  from  without  (changed  excitability,  iucrcased  or  dimin- 
ished; qualitatively  changed) ;  and  a  disturbance  of  consciousness  as 
such  (aside  from  clouding  of  consciousness  as  a  result  of  spontaneous 
subjective  excitement) . 

However,  there  is  danger  that  in  this  state  of  disturbed  con- 
sciousness the  same  value  may  be  given  to  inner  subjective  and  outer 
objective  stimuli  (hallucination,  delusion),  for  the  law  of  eccentric 
psychic  manifestation,  as  shown  in  habit  and  experience,  acts  only 
in  relation  to  objective  events  in  the  outer  world. 

This  clouding  of  consciousness  (disturbance  of  judgment  and  of 
mental  clearness)  forms  the  foundation  for  an  understanding  of  the 
phenomena  of  insanity. 

In  particular,  it  is  the  loss  or  inhibition  of  facts  of  earlier  experi- 
ence (important  for  the  origin  of  delusions)  ;  the  mistaking  (hal- 
lucination) of  central  sensory  excitation  for  that  objectively  induced, 
or  a  mixture  of  the  two  (illusion) ;  or  it  is  the  erroneous  interpreta- 
tion of  impressions  by  disturbed  consciousness  due  to  the  assumption 
of  causal  phenomena  in  the  external  world,  in  accordance  with  the 
law  of  eccentric  projection  in  harmony  with  previous  psychologic 
experience. 

Just  as  inexplicable  as  the  fact  that  consciousness  rests  upon  a 
material  basis  are  the  conditions  necessary  for  abnormal  states  of 
consciousness  in  the  insane.  Only  isolated  causes  of  disturbance  of 
consciousness  can  be  identified ;  such  as  the  inhibition  or  loss  of  mem- 
ory-pictures (mental  blindness,  mental  deafness);  the  inhibition  or 
suspension  of  complete  series  of  experiences  of  normal  mental  life 
which  may  be  due  to  permanent  loss  of  them  (obliteration  of  memory), 
or  result  from  inhibition  consequent  upon  intense  emotional  mental 
states  (disturbances  of  ideational  association),  or  from  disturbances 
of  apperception  (illusion);  and,  last,  from  the  simultaneous  occur- 
rence of  subjective  and  objective  sensorial  impressions  (hallucina- 
tions) . 


CHAPTER  VIII. 
Analogies  of  Insanity. 

The  psychologic  activity  of  the  organ  of  the  mind  results  in  the 
production  of  feelings,  ideas,  and  voluntary  impulses. 

When  these  psychic  processes  arise  spontaneously  or  as  a  result 
of  inadequate  external  excitants,  it  is  in  general  a  sign  of  inner  excita- 


30  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

tion  aiul  anoinnldus  rcnctiim,  the  duration,  ind'iisily.  and  dispro- 
portion of  which  do  not  leave  us  long  in  doubt  of  its  pathologic 
significance.  Thus,  this  manner  of  origin  is  the  first  and  most  impor- 
tant clinicaJ  mark  of  insanity.  The  outward  manifestations  of  the 
insane  and  the  sane  may  be  identical.  Only  when  we  know  the  source 
and  motive  of  psychic  processes  can  we  readily  decide  whether  we  have 
before  us  an  insane  or  sane  person. 

However,  since  insanity  is  made  up  of  the  same  elements  as 
sanity,  and  since  the  same  laws  of  association  and  action  hold  good 
for  both,  the  study  of  physiologic  mental  processes,  as  well  as  the 
observation  of  certain  pathologic  phenomena  that  we  frequently  meet, 
offer  valuable  analogies,  with  the  help  of  which,  as  well  as  of  that 
afforded  by  our  ex|)erience  with  transitory  mental  conditions,  we  are 
enabled  to  gain  a  view  of  the  pathology^  of  mental  life,  and  in  a  meas- 
ure understand  how  the  abnormal  ideational  associations  and  delu- 
sions, the  erroneous  feelings  and  impulses  of  actual  insanity,  arise. 

Everyday  life  furnishes  numerous  analogies  of  this  kind.  Just 
as  in  the  case  of  health  and  disease  in  the  somatic  sphere,  where 
means  of  exact  physical  examination  are  at  command,  we  cannot 
definitely  mark  off  one  from  the  other,  so  it  is  in  the  mental  sphere; 
indeed,  here  we  have  every  reason  not  to  attempt  to  draw  the  line  too 
sharply  between  physiologic  and  pathologic  activity. 

In  the  majority  of  cases,  in  the  beginning  of  mental  disease 
the  important  element  of  the  clinical  picture  does  not  lie  in  the  intel- 
lectual disturbance,  but  in  the  emotions — in  the  lack  or  in  the  insuf- 
ficiency of  motives  for  feelings,  affects,  and  manifestations  of  abnormal 
emotional  irritability.  Comparison  of  these  pathologic  states  of  feel- 
ing with  physiologic  states  of  emotion  is  at  once  suggested. 

Our  usual  manner  of  feeling,  the  quiet  activity  of  our  emotions,  is  capa- 
ble of  imdergoing  a  tumultuous  change.  Under  such  circumstances  we  speak 
of  affects,  and  we  differentiate,  according  as  the  cause  inhibits  or  enhances  our 
mental  interests,  the  depressive  affects  of  surprise,  shame,  care,  trouble,  and 
worry  from  the  expansive  affects  of  pleasure,  joy,  and  wild  delight.  Corre- 
sponding with  these  two  possibilities  of  feeling,  which  lie  within  the  limits  of 
physiologic  conditions  of  life,  we  find  two  pathologic  states  of  emotion, 
namely:  the  melancholic  and  maniacal. 

If  we  compare  the  painful  affect  of  the  normally  depressed  individual 
with  that  of  the  melancholic  patient,  we  find  externally  no  difference;  in  both 
we  find  the  same  facial  expression  of  mental  pain,  the  same  painful  depres- 
sion. Both  are  controlled  by  the  power  of  tlioir  painful  thoughts  and  feel- 
ings; both  are  alike  unable  to  interest  themselves  in  anything  that  lies  out- 
side the  circle  of  ideas  into  which  they  are  forced,  and  are  incapable  of 
attending  to  their  usual  duties  and  occupations;  both  suffer  from  lack  of 
sleep  and  loss  of  appetite,  and  intestinal  peristalsis  is  diminished;    in  both, 


TITE  SUBJECT  AND  ATDS  IN  ITS  .SIIJDY.  31 

general  nutiiiioii  .sinks.  TJie  esseiiLiiil  (liinüciice  Ijclwecn  the  wane  indi- 
vidual who  is  painfully  depressed  and  the  melancholic  lies  in  the  fact  that 
in  the  former  the  mental  pain  has  an  ad(;(juate  motive  and  is  the  physio- 
logic reaction  to  an  external  event,  while  in  the  latter  there  is  no  external  or 
at  least  only  an  insufficient  external  motive,  and  thus  the  condition  is  the 
result  of  inner  processes:  he  imagines  something;  as  a  result  of  disease  his 
brain  does  not  mirror  for  him  pictures  and  ideas  which  correspond  with 
reality,  and  his  consciousness  is  too  disturbed  to  allow  him  to  recognize  the 
counterfeits  with  which  he  is  occupied. 

The  error  of  confounding  normal  mental  depression  and  insane  depression 
is  committed  only  too  frequently  by  the  laity,  who  take  note  only  of  superficial 
resemblances  between  the  two.  This  is  the  more  possible,  because  not  infre- 
quently melancholia  has  its  origin  in  a  state  of  normal  emotional  depression; 
in  the  beginning  physiologic,  it  gradually  passes  into  a  pathologic  condition, 
and  thus  the  cardinal  difl'erence  between  the  physiologic  and  the  spontaneous 
pathologic  psychic  manifestation  is  obliterated.  However,  the  fundamental 
difference  between  the  two  is  demonstrated  by  the  lack  of  success,  when,  the 
depression  being  regarded  as  physiologic,  an  attempt  is  made  to  divert  and 
entertain  the  depressed  individual,  relying  upon  the  effect  of  time,  the  natural 
feeling  of  hope,  and  the  removal  of  depressing  causes. 

While  all  these  expectations  are  fulfilled  with  those  physiologically  de- 
pressed, the  opposite  is  the  case  in  a  person  depressed  as  a  result  of  disease. 
Encouragement  only  embitters  him;  diversion  he  refuses  or  is  even  irritated 
by;  an  attempt  to  convince  him  logically  that  he  is  not  ruined  and  that  he  is 
in  no  danger  quiets  him  for  the  moment,  but  immediately  thereafter  he  ex- 
presses a  new  delusion ;  for  example,  that  he  is  a  criminal.  The  source  of  his  ab- 
normal feelings  and  ideas  is  a  brain  disease ;    it  is  organic,  and  not  psychologic. 

Exactly  the  same  analogies  obtain  in  the  comparison  of  the  expansive 
emotional  states  of  a  healthy  person  with  the  maniacal  conditions  of  the 
insane— at  least,  when  the  former  have  reached  a  certain  intensity.  But  for 
the  purpose  of  comparison  we  must  not  use  highly  cultured  individuals,  who 
in  a  way  have  learned  to  control  their  feelings;  rather  we  should  take 
the  child  who  is  j'et  unskilled  in  the  government  of  the  emotions;  or  the  cul- 
tured individual  in  such  a  state  that  his  emotions  have  become  so  strong  and 
overpowering  that  they  break  through  the  bounds  which  citstoni  has  set 
around  their  expression.  Let  us  imagine  ourselves  in  the  place  of  the  lover 
who  unexpectedly  obtains  the  fulfillment  of  his  wish ;  in  that  of  one  approach- 
ing certain  death  who  unexpectedly  is  saved;  or  in  the  place  of  the  miser  who 
receives  the  news  that  he  has  drawn  the  capital  prize  in  a  lottery.  For  the 
moment  these  persons  could  not  be  outwardly  distinguished  from  the  maniac 
— they  exhibit  foolish  shouting  and  dancing;  overflow  of  wild  delight,  even  to 
the  extent  of  incoherence  of  thought;  and  with  the  overfilled  state  of  con- 
sciousness it  may  go  to  the  extent  of  disconnected  speech  and  cries  and  even 
incoherence  of  ideas.  In  those  wild  with  delight  the  storm  soon  passes;  the 
influence  of  time  soon  makes  itself  felt;  but  with  the  maniacal  the  organic 
condition  of  disturbance  lasts,  it  may  be,  even  weeks  or  months;  indeed,  it 
may  go  on  even  to  exhaustion. 

The  study  of  physiologic  affects  discloses  principles  and  compari- 
sons important  for  an  understanding  of  the  phenomena  of  affective 


32  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

insanity;  indeed,  exact  observation  shows  that  there  is  no  sharp  limit 
between  affects  that  are  in  themselves  entirely  physiologic  and  certain 
other  affects  which,  though  apparently  the  result  of  motive,  are,  ow- 
ing to  their  intensity,  duration,  and  the  accompanying  loss  of  self- 
consciousness,  pathologic;  such  as  those  that  are  observed  in  certain 
persons  of  abnormal  cerebral  organization  and  in  the  neuroses  (epi- 
lepsy, etc.). 

Observation  of  individuals,  of  whom  types  are  very  numerous  in 
both  public  and  private  life,  and  who  sho-w  among  themselves  the 
greatest  difference,  demonstrate  how  variable  the  limit  is  between 
mental  health  and  mental  disease;  indeed,  at  one  extreme  we  may 
have  a  genius,  and  at  the  other  a  fool. 

In  such  individuals  we  observe  peculiarities  in  thought,  feeling, 
and  action;  they  react  to  stimuli  which  do  not  exist  for  or  have  no 
effect  on  others,  and  in  such  a  way  that  they  appear  unusual  and 
peculiar ;  and  thus  such  persons  often  get  the  name  of  being  eccentric 
or  even  foolish  simply  because  the  great  majority  of  mankind  feel  and 
act  otherwdse.  Likewise  the  association  of  ideas  of  such  individuals 
is  unusual :  they  bring  things  into  strange,  unusual,  new,  and  possibly 
interesting  relations,  even  in  some  instances/  pointing  the  way  for 
progress.  But  even  at  the  best  they  are  not  able  to  make  these  new 
thoughts  useful.  Such  persons,  while  not  insane,  are  still  not  exactly 
right ;  they  stand  on  the  threshold  of  insanity,  and  constitute  a  transi- 
tion to  it.  An  understanding  of  these  problematic  natures  is  obtained 
when  their  ancestry  is  studied.  As  a  rule,  they  come  from  insane 
ancestry,  or  at  least  there  are  insane  persons  among  their  blood  rela- 
tions. The  study  of  such  individuals  along  psychiatric  lines  raises 
psychiatry  far  above  the  narrow  horizon  of  a  special  science  and  makes 
it  an  important  practical  science  for  the  mental  history  of  mankind. 

Such  pseudo-geniuses  are  frequently  met  in  public  life;  sometimes  work- 
ing in  the  harmless  domain  of  important  discoveries;  making  propositions  for 
the  furtherance  of  the  general  welfare,  which,  however,  prove  to  be  impracti- 
cable when  carefully  examined;  sometimes  m  politics,  in  the  church,  or  in  the 
State.  Fi-om  their  ranks  spring  inventors,  busybodies,  reformers,  revolution- 
ists, founders  of  new  sects,  whose  plans  gain  for  a  time  the  popular  ear,  but 
whose  work  necessarily  comes  to  naught  because  it  is  nothing  more  than  the 
mental  lightning  of  an  inductive,  but  erroneous,  reasoning  which  has  not 
ripened  out  of  civilization,  even  though  it  be  the  anticipated  mental  product 
of  genius  (Maudsley).  The  study  of  such  problematic  natures  helps  us  to  an 
understanding  of  a  certain  form  of  insanity  (paranoia),  in  which  likewise  the 
one-sidedness  of  certain  efforts  and  the  fixedness  of  certain  absurd  ideas  which 
have  become  the  ruling  thoughts  are  remarkable;  and  frequently  enough,  in 
the  course  of  the  life  of  these  originally  eccentric  natures  paranoia  unnoticed, 
actually  develops. 


THE  SUBJECT  AND  AIDS  IN  ITS  STUDY.  33 

Another  interesting  analogue  of  insanity  is  offered  by  the  phenom- 
ena of  dreams. 

However^  there  is  a  fundamental  difference  between  dreams  and 
insanity,  in  so  far  as  one  is  the  manifestation  of  the  sleeping,  while 
the  other  belongs  to  the  waking,  state.  It  is  to  be  remembered  that 
our  dreams  are  liveliest  when  we  are  in  the  state  of  half-sleep,  and 
that  the  conditions  of  somnambulism  and  sleep-walking  present  transi- 
tions between  sleeping  and  waking.  What  makes  the  phenomena  of 
dreams  especially  instructive  for  our  understanding  of  certain  phenom- 
ena in  insanity  is  the  circumstance  that  in  both  conditions  the  produc- 
tion of  ideas  and  sensory  impressions  arises,  for  the  most  part,  from 
inner  spontaneous  excitation,  in  contrast  with  the  origin  of  these  in  the 
normal  waking  state  from  external  perception  and  association  of  ideas. 

The  causes  of  this  spontaneous  automatic  excitation  of  the  ideational 
centers  in  the  brain  are  internal  stimuli  (changes  in  the  blood) ;  their  results 
are  ideas  (delusions  and  hallucinations)  that  do  not  correspond  with  reality. 

In  both  conditions  the  continued  automatic  excitement  calls  up  com- 
pletely disparate  ideas,  and  the  association  of  ideas,  constantly  disturbed  and 
limited,  is  no  longer  the  arrangement  of  mental  pictures  according  to  their 
logical  content,  but  at  most  merely  an  association  of  them  according  to  super- 
ficial similarity  (which  is  often  conditioned  by  nothing  more  than  the  mere 
similarity  of  the  sound  of  words) ;  and  thus  arises  that  confusion  and  inco- 
herence Avhich  characterize  dreams  as  well  as  certain  conditions  of  insanity. 

A  surprising  similarity  between  the  two  conditions  is  shown  further  by 
the  fantastic  distortion  and  exaggeration  which  some  impressions  coming  from 
the  outer  world  undergo  when  they  reach  the  consciousness  of  the  dreamer  or 
the  insane  person. 

Just  as  the  dreamer  may  take  the  prick  of  a  pin  for  the  stroke  of  a 
dagger,  the  pressure  of  the  bedclothes  for  the  weight  of  mountains,  a  be- 
numbed limb  for  a  paralyzed  member,  bodily  uneasiness  resulting  from  dis- 
turbed respiration  for  nightmare  and  being  buried  alive;  so  the  insane  person 
transforms  his  sensations,  which  often  are  elaborated  into  the  most  astound- 
ing delusions.  A  further  correspondence  is  found  in  the  fact  that  in  both  con- 
ditions not  infrequently  the  personality  is  doubled.  The  insane  person  some- 
times attributes  his  own  thoughts  to  another  personality  (demonomania), 
just  as  in  dreams  we  often  attribute  opposing  ideas  to  other  persons,  dispute 
with  them,  etc. 

But  in  the  insane  it  is  peculiarly  remarkable  that  against  the  evidence 
of  the  senses,  against  all  previous  experiences  or  actuality,  they  hold  fast  to 
the  most  absurd  and  physically  impossible  ideas  which  the  diseased  brain  mir- 
i-ors  before  them  and  which  they  cannot  correct. 

We  meet  the  same  thing  in  dreams.  We  go  through  the  most  absurd 
and  contradictory  experiences  without  doubting  their  reality;  we  are  aston- 
ished at  them,  like  the  insane  person,  and  even  for  the  moment  we  think  they 
must  be  a  dream;  just  as  the  insane  man,  in  the  fleeting  moment  of  his  lucid 
interval,  recognizes  the  specter  of  his  brain,  and  attains  for  the  moment 
recog-nition  of  his  disease. 


34  INTüoDltTlüX  TO  THE  STUDY  OF  PSYCHIATÜY. 

The  cause  of  tlio  plicnomenon  in  the  dreaming  person  lies  in  the  tempo- 
rary suspension  of  the  processes  of  deduction  and  judgment  which  underlie  the 
higher  psychic  activities,  and  the  lack  of  control  tlnough  the  higher  senses, 
which"  are  shut  ofT  from  the  outer  world. 

In  the'  insane,  correction  is  impossible  because  of  disease  of  the  psychic 
organ,  and  because  of  the  disturbance  of  consciousness  by  subjective  impres- 
sions (hallucinations). 

It  is  remarkable  that  pleasant  dreams  in  the  sand  person,  like  joyful  de- 
lusions in  the  insane,  are  much  less  frequent  than  those  of  an  opposite  char- 
acter. Kxpericuce  shows  that  pleasant  dreams  are  most  frequent  at  times  of 
mental  and  pliysical  exhaustion.  \\'e  see  the  same  thing  in  the  insane,  where 
delusions  of  grandeur  most  frequently  accompany  mental  decay  and  disease- 
processes  which  lead  to  the  destruction  of  the  brain,  and  therefore  their'  occur- 
rence tinder  such  circumstances  indicates  a  bad  prognosis. 

The  similarity  of  certain  states  of  consciousness  in  dreams  and  some 
forms  of  insanity  is  further  shown  by  the  statements  of  many  who  have  re- 
covered from  mental  disease,  to  the  elfect  that  the  whole  period  of  their  sick- 
ness seems  like  a  dream. 

The  process  of  recovery  from  insanity  also  often  resembles  that  of  awak- 
ing from  a  dream.  Sometimes  it  is  sudden,  as  if  scales  had  fallen  from  the 
patient's  ej-es,  and  he  realizes  that  he  was  delirious;  but  more  frequently  the 
realization  of  this  is  gradual.  The  creations  of  insane  thought,  like  the 
dream-pictures  of  the  somnambulist,  are  carried  over  into  the  lucid  state;  so 
that  the  convalescent  succeeds  in  recognizing  his  disease  and  its  products  only 
after  troublesome  and  painful  processes  of  thought,  after  a  struggle  between 
the  fantastic  ideas  and  reality. 

By  far  the  most  striking  and  comprehensive  analogy  with  insanity 
is  offered  by  acute  alcoholic  intoxication.  In  this  condition  we  find 
exemplified  all  forms  of  insanity,  from  the  mildest  melancholic  condi- 
tions, like  so-called  drunken  misery,  to  the  most  extreme  degrees  of 
interruption  of  the  mental  functions,  which  could  not  be  more  com- 
plete in  terminal  dementia. 

But  even  the  gravest  form  of  insanity,  dementia  paralytica,  is 
often  so  truly  copied  in  drunkenness  that  with  passing  observation 
it  is  only  by  means  of  the  history  that  we  are  able  to  determine  whether 
we  have  before  us  acute  alcoholic  paralysis  or  the  incurable  parah^sis 
of  the  insane. 

Drunkenness  is  really  nothing  more  than  an  artificial  insanity,  and  we 
find  in  it  two  fundamental  psychiatric  facts,  namely:  that,  in  accordance  with 
constitutional  conditions,  the  common  cause  may  induce  disease-pictures  that 
are  entirely  difTerent;  and  that  the  conditions  of  psychic  paralysis  as  pre- 
sented in  the  stage  of  senseless  drunkenness  and  in  terminal  dementia  conse- 
quent upon  insanity  are  preceded  by  states  of  excitement.  In  the  majority  of 
cases  the  first  effects  of  alcohol  are  manifested  in  slight  maniacal  excitement; 
the  physical  and  mental  activities  are  increased,  and  the  flow  of  ideas  is  facili- 
tated. The  silent  become  talkative,  the  quiet,  lively;  an  increased  sense  of 
self  leads  to  assertiveness,  brusqueness,  and  joyfulness;  an  intensified  desire 


THE  SUßJPXJT  ANJJ  AIDS  IN  JTS  ÜTVDY.  35 

for  muscular  movement,  a  iruc  impulse  to  movement,  expresses  itself  in  sin;,'- 
ing,  crying,  laughing,  dancing,  and  all  sorts  of  emotional  and  purposeless  nets. 
At  this  stage,  still  conscious  of  the  laws  of  propriety,  the  forms  of  politeness 
are  observed,  and  a  certain  degree  of  self-control  is  manifested.  With  the  in- 
creasing influence  of  alcohol,  however,  just  as  with  the  maniac,  esthetic  ideas, 
as  well  as  moral  judgment,  which  in  the  normal  condition  are  at  the  command 
of  the  ego  and  inhibit  and  control,  disappear.  Now  the  drunkard  gives  him- 
self full  rein,  shows  out  his  frailties  of  character,  discloses  his  secrets  (in  vino 
Veritas),  and  rises  above  propriety.  He  becomes  cynical,  brutal,  self-assertive, 
and  violent.  Now  he  has  lost  power  to  judge  of  his  own  condition;  he  is  as 
far  from  thinking  himself  drunk  as  the  insane  man  is  from  thinking  himself 
insane,  and  he  files  angry  when  told  his  true  condition.  Finally  he  passes 
into  a  state  of  mental  weakness,  to  complete  clouding  of  consciousness. 
Phantasms  of  the  senses  occiu*  (illusions),  confusion  comes  on,  and  at  last 
a  state  of  deep  stupor,  following  stumbling  speech,  staggering  gait,  and  uncer- 
tain movements,  exactly  like  those  of  a  paralytic,  closes  the  repulsive  scene. 

The  similarity  of  this  artificial  insanity  and  the  actual  is  further 
shown  in  that  sometimes,  but  always  as  a  result  of  peculiar  predisposi- 
tion, drunkenness  takes  the  form  of  acute  delirium  or  transitory 
mania;  so  that  now  and  then  intoxication  becomes  the  immediate 
cause  of  a  lasting  insanity. 


PART  SECOND. 

Historic  Review  of  the  Development  of  Psychiatry 

as  a  Science» 


The  view  expressed  that  the  brain  is  the  organ  of  psychic  activi- 
ties and  tliat  mental  disease  has  the  same  signillcance  as  cerebral 
disease  is  the  result  of  a  progressive  growth  of  knowledge  which  must 
be  accounted  one  of  the  greatest  achievements  of  the  Imman  mind. 

In  telling  us  of  this  grand  achievement  the  history  of  psychiatry 
discloses  the  difficulties  which  stood  in  the  way,  and  at  the  same  time 
impresses  upon  us  the  relatively  meager  mass  of  positive  knowledge 
which  is  at  the  command  of  this  young  branch  of  medical  science. 
It  also  brings  us  to  a  closer  understanding  of  many  of  the  disputed 
questions  of  the  present  day,  and  opens  up  views  of  the  goal  and 
hopes  of  the  future. 

The  history  of  psychiatry  forms  one  of  the  most  interesting  pages 
in  the  history  of  human  civilization.  It  tells  us  of  grossest  errors;  of 
victims  of  torture  and  witches,  who  were  only  insane  persons;  of  the 
inhumanity  of  past  centuries;  of  insane  persons  left  to  languish  in 
prisons,  penned  up  with  the  commonest  criminals,  loaded  with 
chains, — the  victims  of  ignorance,  and  abandoned  to  the  cruelty  of  a 
jailer  Avho  had  no  ear  or  heart  for  the  cry  of  suffering  and  plied  the 
whip  mercilessly  on  the  backs  of  the  unfortunate. 

But  it  also  tells  of  the  long  and  hard,  though  victorious,  struggle 
which  science  and  humanity  fought  with  error,  cruelty,  and  super- 
stition. 

It  is  the  story  of  nothing  less  than  the  destruction  of  ancient 
prejudices,  which  saw  in  the  unfortunate  insane  only  those  who  had 
lost  the  attributes  of  humanity,  and  had  become  animals,  mentally 
dead,  and  abandoned  by  God;  which  regarded  these  unfortunate 
beings  as  persons  possessed  by  evil  powers,  as  outcasts  and  criminals. 
The  result  of  this  conflict  was  the  foundation  of  psychiatry  as  a  science 
and  the  care  of  this  unfortunate  class  of  humanity  in  institutions 
suited  to  carry  out  their  humane  purpose.  The  history  of  psychiatry 
covers  only  a  short  interval  in  the  history  of  insanity. 
(36) 


HISTORIC  REVIEW  OP  THE  DEVELOPMENT  OF  PSYCHIATRY.     37 

The  innumerable  causes  of  this  form  of  disease  justify  ug  in  the 
assumption  that  in  the  very  earliest  times  of  man's  existence  mental 
diseases  occurred,  but  a  thick  veil  covers  the  life  and  suffering  of  those 
who,  during  the  period  of  scientific  darkness  and  error,  were  afflicted 
with  delusion  and  mental  disease. 


CHAPTER  I. 
Psychiatry  in  Ancient  Times. 

The  beginning  of  the  history  of  insanity  is  lost  in  the  darkness  of  ancient 
ages.  What  we  know  of  the  occurrence  of  mental  disease  in  those  distant 
times  is  limited  to  occasional  allusions  in  the  Old  Testament  and  in  works  of 
poetry.  Thus,  it  is  said  that  the  spirit  of  the  Lord  chastised  Saul  and  troubled 
him  with  an  evil  spirit,  and  that  during  his  attacks  of  mental  disturbance  he 
found  diversion  in  listening  to  David's  playing  on  the  harp.  The  book  of 
Daniel  relates  of  Nebuchadnezzar,  King  of  Babylon,  that  he  thought  he  was 
changed  into  an  animal  and  despised  of  men;  that  he  ate  grass  like  an  ox, 
and  that  his  body  lay  under  the  dew  of  heaven  and  became  wet,  till  his  hair 
grew  like  the  feathers  of  an  eagle  and  his  nails  like  bird-claws.  David  offers 
an  illustration  to  the  effect  that  even  at  this  ancient  time  insanity  was  simu- 
lated, for,  out  of  fear  of  the  anger  of  King  Aschisch,  he  simulated  insanity, 
and  thus  gained  his  end. 

The  works  of  poets  are  no  less  rich  in  examples.  The  sly  Odysseus  pre- 
tended to  be  insane  in  order  to  escape  the  necessity  of  joining  in  the  Trojan 
War;  and  Ajax,  the  hero  of  the  Iliad,  was  tortured  by  Furies:  i.e.,  he  became 
insane,  and  threw  himself  upon  his  sword.  Examples  of  melancholia  are 
offered  by  QEdipus  and  Orestes,  who,  according  to  the  poetic  ideas  of  that  time, 
were  pursued  by  Eumenides.  An  example  of  lycanthropia  is  the  insanity  of 
King  Lykaon  of  Arcadia. 

We  may  assume  that,  at  a  time  when  the  natural  sciences  were  at 
the  lowest  i^oint  of  their  development,  correct  appreciation  of  such 
abnormal  mental  conditions  was,  for  the  most  part,  wanting,  and  that 
usually  they  were  ascribed  to  the  supernatural  influences  of  secret 
powers — of  gods  or  evil  demons.  The  treatment  of  such  diseases, 
therefore,  was  limited  to  religious  ceremonies,  exorcism,  and  charms. 

Those  so  afflicted  were  either  honored  as  holy,  as  happens  in  the 
Orient  even  to  this  day,  or  given  to  the  influence  of  religion,  as  among 
the  old  Egyptians,  who  had  a  temple  dedicated  to  Saturn,  where  they 
sent  those  afflicted  with  melancholia. 

Psychiatry  remained  in  this  condition  until  the  time  of  Hip- 
pocrates (460  B.c.).  With  him,  however,  it  underwent  decided  scien- 
tific advancement.  He  took  these  cases  from  the  hands  of  the  priests, 
who,  in  temples  dedicated  to  iEsculapius,  treated  such  patients  and 
gave  oracular  consultations. 


3S  INTKODUCnON  TO  THE  STUDY  OF  PSYCHTATRY. 

The  Ilippocratic  theory  of  mental  disease  may  be  expressed  in  the 
following  sentences,  as  a  translation  into  the  scientific  language  of 
to-day :, The  brain  is  tlio  seat  of  mental  activity,  and,  like  other  organs, 
is  obnoxious. to  the  natural  causes  of  disease.  Mental  diseases  arise 
from  abnormalities  of  tlie  brain. 

As  is  well  kiiDwn,  llippociates  was  the  father  of  humoral  pathology; 
according  to  hiiu,  the  principle  causes  of  insauity  were  abnormal  changes  of 
the  four  cardinal  fluids  (blood,  mucus,  and  black  and  yellow  bile);  but  the 
significance  of  preilisposition  did  not  entirely  escape  the  genius  of  Hippocrates, 
\  and  he  also  recognized  acute  and  chronic  diseases  of  the  vegetative  organs  as 
causes  of  mental  disturbance.  Apparently'  Hippocrates  did  not  separate 
actual  insanity  from  the  delirium  of  fever,  but  included  both  in  the  common 
term  phrenitis.  Insanity  occurred  siuldenij-  and  ended  quickly,  or  continued 
for  a  long  time.  He  also  alludes  to  individuals  who  closely  resembled  the  in- 
sane, but  who  were  not  actually  insane..  Among  mental  diseases  he  recognized 
melancholic  and  maniacal  conditions;  also  states  of  mental  weakness. 
Xervous  diseases,  especially  convulsions,  passed  easily  into  insanity,  and 
then  the  prognosis  was  unfavorable.  For  the  most  part,  mental  diseases  were 
curable  ami  seldom  fatal;  the  treatment  was  somatic — that  is,  medical  and 
dietetic.  Still,  the  temperament  upon  which  the  mental  disturbance  was  de- 
veloped was  never  to  be  left  out  of  account.  In  general,  the  melancholic,  or 
black-bile,  temperament  predominated,  and  therefore  Hippocrates  used  deplet- 
ing measures,  such  as  hellebore,  which,  among  the  ancients,  was  much  in  use 
for  the  treatment  of  the  insane.  Other  means  were  bloodletting,  emetics, 
rigorous  diet,  and  rest. 

From  these  indices  it  is  clear  that  the  great  physician  of  antiquity 
was  not  so  far  from  the  theories  of  to-day.  He  was,  at  any  rate,  the 
first  who  clearly  recognized  that  in  these  conditions  the  brain  is  the 
organ  at  fault,  and  that  insane  states  are  not  the  result  of  supernatural 
influences,  but  physical  disturbances  like  other  diseases.  The  Hip- 
pocratic  tlieory  became  the  dogma  of  succ(icding  generations,  though 
some  advance  may  still  be  recognized.  Aretseus  (GO  a.d.)  gives  a  good 
description  of  melancholia  and  mania,  and  enlarges  the  scope  of  diag- 
nosis and  prognosis,  tliough  in  etiology  he  was  not  beyond  liis  groat 
predecessor. 

Galen  (160  a.d.)  also  held  to  the  principle  tliat  mental  disease 
has  the  same  significance  as  brain  disease.  He  made  some  advance,  in 
that  he  distinguished  in  the  insane  state  a  primary  cerebral  disease 
and  a  deuteropathic  condition,  the  result  of  affections  of  otlier  organs, 
especially  of  the  abdominal  viscera.  He  also  sharply  differentiated 
the  delirium  of  fever  (phrenitis)  from  actual  insanity. 

A  prominent  figure  in  the  domain  of  psychiatry  is  Coelius  Aureli- 
anus,  a  contemporary  of  Trajan  and  Hadrian.  He  considered  the 
various   forms   of   chronic   mental   disease  merely   as   fundamental 


HISTORIC  REVIEW  OF  THE  DEVELOPMENT  OF  PSYCHIATRY.     39 

varieties  of  one  and  the  same  disease,  and  lie  happily  emancipated  him- 
self from  the  Hippocratic  theory  of  cardinal  humors.  He  recognized 
only  somatic  and  psychic  causes.  His  method  of  treatment  is  clearer 
and  more  precise  than  that  of  all  those  who  preceded  him;  and  he 
cast  aside  almost  entirely  restraint  and  force  as  means  of  treatment. 
He  emphasized  the  fact  that  mental  diseases  were  nothing  but  cerebral 
diseases  with  predominating  mental  symptoms;  and  that  therefore 
they  belonged  to  the  domain  of  the  physician;  for  no  philosopher 
had  as  yet  been  able  to  cure  them.  With  Coelius  Aurelianus  this  early 
and  promising  advance  of  psychiatry  among  the  great  Greek  and 
Eoman  physicians  came  to  an  end. 


CHAPTER  IL 
Psychiatry  in  the  Middle  Ages. 

The  period  of  decline  of  the  ancient  Eoman  Empire  and  its  civil- 
ization, and  the  migration  of  the  people  which  followed,  were  not 
favorable  for  the  development  of  the  science.  Medicine  deteriorated 
and  led  a  troubled  existence  in  cloisters,  among  the  Arabs,  and  in 
such  guild-schools  as  that  of  Salernum.  As  might  have  been  ex- 
pected, the  retrogression  was  most  pronounced  in  the  branch  of  medi- 
cine least  understood — psychiatry. 

In  place  of  empiric  scientific  investigation,  magic,  mysticism,  and 
superstition  arose.  The  views  of  the  Xew  Testament,  which  looked 
upon  the  insane  as  persons  possessed  of  evil  demons,  were  not  favorable 
for  the  advancement  of  knowledge ;  and  therefore  it  should  be  no  cause 
for  wonder  that,  as  in  earlier  ages,  the  treatment  of  the  insane  con- 
sisted almost  exclusively  of  exorcism,  castigation,  and  magical  and 
inquisitorial  means — indeed,  even  of  torture  and  capital  punishment. 

The  errors  of  earlier  centuries  were  again  reproduced  in  the  delusions  of 
the  unhappy  insane,  who,  during  the  Middle  Ages,  for  the  most  part  expressed 
their  abnormality  in  demonomania  or  possession. 

Tlie  treatment  of  the  insane  fell  to  the  priests,  who,  in  blind  fanaticism, 
combated  the  dangerous  witches  and  devils  with  the  stake  and  torture,  or 
sought  to  drive  out  the  evil  spirits  by  violent  exorcism. 

Innumerable  were  the  witch-trials,  and  alike  innumerable  were  the  mi- 
fortunates  put  to  death— principally  melancholies.  Thus,  in  the  principality 
of  Trier,  within  a  few  years  6500  persons  were  executed  as  possessed  and  be- 
witched. 

Maniacal  persons,  hardly  less  to  be  pitied,  were  cast  into  dark  prisons, 
chained  like  wild  beasts,  and  left  to  die  in  filth  and  misery.  Only  a  few 
patients,  whose  delusions  gave  no  offense  to  the  church,  found  here  and  there 
rest  in  the  cloisters  and  eleemosynary  institutions. 


40  INTROnrcTlOX  TO  THK  STUDY  OF  PSYClllATRY. 

Thus  for  centuries  the  fate  of  the  insane  remained  the  same.  Though 
Charles  the  tJreat  had  forbidden  the  burning;  of  witclies,  and  the  noble  Wier 
(1515)  had  applied  to  both  emperor  and  tlic  people  Avith  a  petition  to  spare 
tlie  blood  of  tlie  sup]>osed  witches,  who  wore  only  melancholic,  insane,  or  hys- 
teric, yet  these  isolated  voices  were  without  eflect  upon  the  superstitious 
nuisses,  whose  prejudices  were  nourished  bj-  the  church.  Thus  it  happened  that 
witch-trials  continued  to  occur  as  late  as  the  eighteenth  century. 

"With  the  age  of  the  Reformation  began  a  better  time  also  for 
medicine,  but  it  was  long  before  medicine  emerged  from  the  struggle 
with  superstition,  mysticism,  and  scholasticism  ;  freed  herself  from 
the  bonds  of  the  church  and  the  blind  authority  of  tlic  ancients;  and 
was  supported  by  the  positive  investigations  of  Vesalius  and  the  unan- 
swerable polemics  of  Paracelsus. 

As  early  as  the  sixteenth  century  in  the  domain  of  psychiatry  the 
beginnings  of  a  clearer  understanding  are  apparent.  Wier's  enlighten- 
ing efforts  were  supported  by  Porta  and  Zachias.  The  writings  of 
Prosper  Alpin,  Mercurialis,  Bellini,  and  Fernelius  disclose  the  first 
signs  of  a  new  scientific  revision  of  psychiatry.  Felix  Plater  (1537- 
1614)  even  attempted  a  classification  of  mental  diseases. 

The  influences  of  Bacon  and  Harvey  mark  initial  stages  of 
advancement  in  the  natural  sciences. 

In  psychiatry  the  beginnings  were  puerile.  For  a  long  time  it  was  dis- 
puted whether  the  insane  were  possessed  by  evil  spirits,  and  therefore  to  be 
left  to  the  priests,  or  whether  they  were  patients  to  be  treated  by  physicians. 
The  most  enlightened  among  the  physicians  were  still  in  doubt  whether  the 
nature  of  insanity  was  to  be  attributed  to  disturbances  of  the  Hippocratic 
himiors.  Attempts  at  cure  were  either  trifling  or  entirely  wanting;  they 
demonstrated  only  to  what  a  depth  science  had  fallen.  Just  as  in  the  earlier 
times  attempts  were  made  to  drive  out  the  devil,  so  now  physicians  soiight  to 
drive  out  delusion;  and,  ignorant  of  its  origin  and  nature,  they  made  use  of 
the  most  ridiculous  measures. 

A  patient  who  believed  himself  to  have  no  head  was  to  be  cured  by  hav- 
ing a  hat  of  lead  put  on  his  head;  to  an  hysteric  woman  who  believed  she 
had  a  snake  in  her  stomach,  an  emetic  was  to  be  given,  and  a  lizard  placed  in 
the  vomit;  a  patient  who  thought  himself  so  cold  that  he  believed  nothing 
but  fire  could  give  him  back  his  natxiral  w'armth,  Zacutus  Lusitanus 
(1571-1642)  sewed  up  in  furs,  which  he  set  on  tire. 

An  excellent  picture  of  the  life  and  suffering  characteristic  of  that  time 
is  given  by  Stenzel  in  his  history  of  the  Prussian  State.  It  is  the  story  of 
Johann  Wilhelm,  Duke  of  Jülich,  son  of  William  the  Rich  and  Maria  of  Aus- 
tria, who  both  suffered  the  sad  fate  of  becoming  insane.  The  duke  was  men- 
tally weak  from  his  youth,  and  never  capable  of  ruling  his  people.  Before  he 
became  completely  insane  he  was  troubled  with  the  groundless  idea  that  some 
one  wished  to  kill  him.  and  therefoi^  he  spent  many  nights  sleepless  in  his 
armor.      After  he  had  wounded  many  of  the  people  of  the  court  in  an  out- 


HISTORIC  EEVIEW  OF  THE  DEVELOPMENT  OF  PSYCHTATMY.     4I 

break,  it  bec-amc  necessary  to  confine  liim.  On  tlic  advice  of  a  priest  and  a 
nun,  tlie  gospel  of  St.  John  was  sewed  inside  of  his  doublet,  and  the  host  was 
given  with  his  food,  but  all  in  vain.  Equally  fruitless  were  the  well-paid 
exorcisms  of  the  monks.  The  advice  of  physicians  was  also  obtained;  but 
they  knew  of  nothing  with  which  to  combat  the  evil,  and  thus  the  duke  was 
left  to  himself,  until  finally  relieved  by  death. 

This  was  the  condition  of  therapeutics  but  a  few  centuries  ago;  the 
majority  of  insane  were  left  to  themselves,  without  protection  and  rights,  or 
even  given  up  to  persecution. 

As  late  as  the  year  1573,  an  act  of  the  English  Parliament  allowed  tlio 
peasants  to  hunt  those  who  were  called  werewolfs,  because  in  their  delusions 
they  thought  themselves  wild  animals,  and  ran  about  in  the  forest.  A  patient 
in  Padua  who  thought  himself  a  werewolf,  and  who  said  that  the  hair  had 
grown  inward,  had  his  arms  and  legs  cut  off  in  order  to  ascertain  whether 
this  was  true  or  not,  and  he  bled  to  death  in  consequence. 

In  many  places  the  insane  were  called  Abraham's  men.  They  were  gen- 
erally avoided;  only  here  and  there  was  manifested  a  feeling  of  pity,  though 
mixed  with  superstitious  fear,  which  provided  them  sparingly  with  nourish- 
ment and  care.  For  the  most  part,  inquisitors  and  exorcisors  took  the  place 
of  the  physician  of  to-day. 

The  biographies  of  persons  of  high  position  which  history  gives  us  show 
that  even  wealth  and  position  were  helpless  against  the  prejudice  and  igno- 
rance of  the  age. 

Thus  it  happened  to  the  unfortunate  Joanne  of  Castile,  the  mother  of 
the  Austrian  imperial  house,  who,  after  the  death  of  her  husband,  Philip  the 
Beautiful,  became  insane,  and  would  have  svmk  into  filth  and  misery  had  not 
Cardinal  Ximenes  come  to  her  rescue;  and  her  great  uncle,  Emperor  Rudolph 
II,  suffered  a  scarcely  better  fate. 


CHAPTER  III. 
The  Rehabilitation  of  Psychiatry  at  the  End  of  the  Eighteenth  Century. 

Until  the  middle  of  the  eighteenth  centitry  the  lot  of  the  insane 
was  a  very  sad  one.  Although  better  views'  of  the  nature  of  these  sad 
conditions  of  disease  had  gradually  been  developed,  and  even  though 
discerning  physicians  had  an  inkling  of  the  fact  that  insanity  was  the 
expression  of  abnormal  disturbances  of  cerebral  and  nervous  activity, 
still  the  important  fact  that  these  diseases,  when  early  recognized  and 
properly  treated,  like  many  others  were  curable,  was  not  yet  under- 
stood. 

As  long  as  this  truth  was  not  grasped  society  looked  upon  the 
insane  as  lost  members;  the  State  saw  in  them  a  burden  and  danger, 
and  only  felt  easy  with  regard  to  them  when,  prejudiced  by  the  thought 
of  their  incurability,  it  had  placed  them  behind  lock  and  kc}',  in  the 
hands  of  jailers,  as  persons  dangerous  to  society. 


42  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

This  -was  the  state  of  things  during  the  time  of  the  crazy-hoiiso, 
of  which  Kaulbach  has  given  such  a  striking  picture.^  But  the  time 
for  a  change  had  come.  Ever  louder  and  more  insistent  became  the 
voices  of  physicians  and  phihmthropists,  which,  from  the  standpoint 
of  liumanity,  called  attention  to  the  fact  that  the  insane  were  still 
liuiuan,  and  pointed  from  occasional  recoveries  which  the  power  of 
Xature  had  brought  about,,  even  amid  the  most  unfavorable  circum- 
stances of  the  craz3'--house,  to  the  possibility  of  curing  the  iiisane  by 
improving  their  material  surroundings;  and  this  was  emphatically 
demanded  of  the  indolent  administration. 

The  first  country  in  which  the  cure  of  the  insane  as  a  whole  was  at- 
teini^ted  was  Enyland,  where,  about  tlie  middle  of  the  eighteenth  century, 
a  hospital  was  fovmded,  St.  Liike's,  iu  London,  though  it  was  still  very  primi- 
tive; but  this  happened  at  a  time  when  on  the  Continent  there  were  no  other 
institutions  than  jails,  crazy-houses,  and  places  of  detention  for  the  confine- 
ment of  such  unfortunates. 

The  success  of  St.  Luke's  Hospital  led  the  Quakers  of  York  soon 
afterward  to  erect  there  an  asjdum  for  the  insane  of  their  order, 
Avhich  received  the  name  of  "  The  Eetreat."  iVbout  the  same  period 
(1777)  Cullen  gave  a  stimulus  to  the  scientific  advancement  of  psy- 
chiatry in  England,  and  his  efforts  were  seconded  by  such  physicians 
as  Arnold,  Pargeter,  Haslam,  and  Perfect. 


*The  beginnings  of  the  transformation  of  crazy-houses  from  institutions 
for  the  punishment  and  detention  of  the  insane  into  hospitals  dates  from  17S0 
in  France.  It  seems  that  the  impulse  to  this  change  was  given  by  the  phi- 
lanthropist, John  Howard,  and  Emperor  Joseph,  who  at  the  time  was  sojourn- 
ing in  France.  Christianity  had  no  proper  appreciation  of  the  insane,  since  it 
looked  upon  them  as  persons  possessed  of  the  devil.  Care  of  the  insane  was 
inidertaken  by  the  Turks,  Avho  long  before  the  time  of  Christ  had  institutions 
for  the  reception  of  such  persons.  The  monks  of  the  order  of  the  Mersi,  who, 
on  account  of  the  ransoming  of  Christian  prisoners,  had  much  intercourse  with 
the  Mussulmans,  became  acquainted  with  these  institutions,  and  in  1409  they 
erected  in  Valencia,  Spain,  the  first  asj'lum  for  the  insane  on  the  Oriental 
plan.  Similar  institutions  were  soon  erected  in  Saragossa,  Seville,  Valladolid, 
and  Toledo.  The  first  Mussulman  asylum  was  that  at  Fez,  which,  according 
to  Leo  Africanus,  was  erected  in  the  seventh  century.  By  the  Spaniards  the 
care  of  the  insane  Avas  spread  to  Italy,  where  at  Bergamo,  probably  in  1852, 
and  at  Florence  in  1387,  and  certainly  at  Rome  in  1548,  asylums  were  erected. 
In  the  beginning  of  the  seventeenth  century  the  hospitals  in  France  began  to 
undertake  'the  care  of  the  insane.  In  1660  the  HOtel-Dieu  was  set  apart  for 
them.  At  about  that  time  the  city  of  Paris  took  care  of  about  40  insane.  As 
late  as  1818  Esquirol  reported  to  the  ministry  that  the  insane  in  France  were 
worse  cared  for  than  criminals  and  animals.  ("Rapport  du  service  des  aliünes 
de  1874,"  page  11.) 


HISTORIC  EEVIEW  OF  THE  DEVELOPMENT  OF  PSYflllATEY.     4^, 

In  France,  in  17G5,  Lorry  pul)lislicd  a  good  dcscrjpti\e  work  on 
insanity;  but  it  was  Pincl  w)io,  tlioiigii  at'  first  entirely  under  tlie 
influence  of  Locke  and  ConcI iliac,  gave  hiraself  to  the  study  of  mental 
diseases.  His  immortal  claim  to  distinction,  however,  lies  in  tlie  fact 
that,  as  physician  to  Bicetre,  in  1792  he  struck  the  chains  from  the 
patients,  taught  that  they  should  be  treated  as  human  beings,  and  gave 
impulse  to  reform  in  the  care  of  the  insane  that  has  extended  to  all 
civilized  lands. 

In  Germany  it  was  Langermann  who,  having  been  placed  at  the  head  of 
medical  affairs  in  Prussia  in  1810,  did  great  service  in  the  reform  of  the  care 
of  the  insane;  but  he  also  did  much  to  further  the  scientific  advancement  of 
psychiatry. 

Among  the  Italians  Chiarugi  deserves  special  mention,  for  his  text-book 
was  held  in  high  regard  for  a  long  time,  and  even  before  Pinel  he  advocated 
more  humane  treatment  of  the  insane. 

But  it  remained  for  the  nineteenth  century  to  mark  the  mighty 
advance  of  psychiatry  and  its  close  union  with  other  branches  of 
medicine. 

While  the  initiative  in  reform  and  humanization  of  the  care  of  the 
insane  are  to  be  ascribed  exclusively  to  the  Italians,  French,  and  Eng- 
lish, all  civilized  nations  may  lay  equal  claim  to  having  helped  on  the 
progress  of  psychiatry  as  a  science. 

In  France,  Esquirol  is  a  prominent  figure  as  the  investigator  of  important 
questions,  especially  with  relation  to  statistics,  and  also  as  the  earliest  clinical 
teacher  in  France.  Following  him,  valuable  anatomic  and  clinical  studies  were 
made  by  Georget,  Bayle,  Calmeil,  Foville,  and  Leuret.  The  first  exact  knowl- 
edge of  paralytic  dementia  we  owe  to  our  French  colleagues.  Among  the 
prominent  French  alienists  of  modern  times  may  be  mentioned  Morel,  Falret 
(father  and  son),  Brierre  de  Boisniont,  and  Legrand  du  Saulle;  in  the  depart- 
ment of  administration  Ferrus  and  Parchajipc  have  done  good  service. 

English  psychiatry  has  been  made  prominent  by  Cox,  Willis,  Ellis,  and 
Prichard,  among  the  older  alienists;  and  by  Bucknill,  Robertson,  and  Mauds- 
ley  of  a  later  date;  while  Conolly  claims  the  distinction  of  having  promul- 
gated the  theory  of  non-restraint  in  the  treatment  of  the  insane. 

In  Holland  psychiatry  made  progress  under  Schröder  Van  der  Kolk,  the 
famous  anatomist,  physiologist,  and  neuropathologist;  in  Belgium,  imder 
Guislain;  in  Russia  under  Balinsky;  in  Sweden  imder  Oehrström,  Kjellberg, 
and  Sandborg.  In  Germany  there  were  many  obstacles  to  hinder  the  rapid 
development  of  psychiatry  as  a  natural  science,  arising  out  of  the  one-sided 
metaphysic  and  psychologic  direction  of  thought  consequent  ujion  the  influ- 
ence of  the  theories  of  Kant  and  the  natural  philosophy  of  Schilling.  Work- 
ing in  this  purely  pliilosophico-psychologic  direction  of  thought  we  find  such 
men  as  Hofibauer,  Reil,  and  Blumroder,  but,  before  all,  Heinroth,  Professor  of 
Psychiatry  in  Leipzig.  It  Avill  suffice  to  sketch  the  principal  theories  of  the 
latter  in  order  to  give  an  idea  of  the  entire  schooL 


44  INTRODUCTION  TO  THE  STUDY  OF  PSYCHIATRY. 

Iloinrolli  rogardcd  the  soul  as  a  free  force  excitable  to  stinuili,  but  en- 
dowed with  the  power  of  choice;  for  him  the  body  was  not  sonietliing  inde- 
pendent, but,  as  it  were,  an  organ  of  the  soul.  The  fundamental  law  of  the 
soul  is  freedom;  the  source  of  its  life,  reason.  Heinroth's  etiologj'  is  of  an 
ethico-religious  nature.  All  human  evils  arise  from  sin;  therefore  mental 
disturbances  have  the  same  origin.  The  soul  is  responsible  for  its  own  dis- 
ease. Passions  and  sins — that  is,  the  fall  from  grace — are  the  causes  of 
mental  diseases.  The  principal  elements  in  their  treatment  were  psychic;  that 
is,  a  pious  life  and  absolute  devotion  to  God  and  all  that  is  good.  According 
to  Heinroth,  the  only  prophylactic  against  insanity  is  Christian  faith. 

Strange  to  say,  this  mystic  and  pious  theory  of  lleinroth  found  ad- 
herents, among  whom  was  Bcneke,  who,  though  he  did  not  follow  the  theory 
in  its  fullest  sense,  still  found  the  essential  element  of  insanity  in  its  psychic 
aspect,  and  tiius  treated  the  psychoses  from  the  one-sided  psychic  standpoint. 

Another  advocate  of  this  theory  is  Ideler,  who,  unfortunately  with  too 
gi'eat  dialectics  and  acuteness,  regarded  mental  diseases  from  a  purely  ethic 
standpoint,  and  held  them  to  be  nothing  but  abnormally  intensified  passions. 
Just  opposition  to  these  errors  could  not  long  be  wanting.  The  2>rincipal 
opponent  in  the  scientific  school  who  fought  these  spiritual,  ethic,  and  psycho- 
logic theories  was  Nasse,  the  celebrated  clinician  of  Bonn,  who,  through  his 
journal  for  alienists  founded  in  1818,  gave  the  first  impulse  of  opposition; 
other  opponents  were  Vering,  Friedreich,  and  Amelung,  who  at  least  held  fast 
to  the  view  that  the  seat  of  mental  disease  was  the  brain.  But  it  was  Jacobi 
who  in  his  zeal  to  find  a  somatic  basis  for  insanity  so  far  overshot  the  mark 
that  he  placed  the  seat  of  mental  disease  in  organs  outside  of  the  skull,  and 
regarded  mental  disturbances  only  as  a  symi)tom  which  might  accompany  any 
disease  of  the  vegetative  organs,  and  thus  gave  but  a  very  subordinate  value 
to  the  brain  aflfection,  which,  according  to  his  view,  was  secondary. 

In  spite  of  this  one-sidedness,  he  is  entitled  to  the  credit  of  having 
Bmoothed  the  way  for  scientific  and  clinico-anatomic  methods  of  study  whicli 
brought  success;  of  having  directed  attention  to  the  very  important  diseases 
and  disturbances  of  vegetative  organs  which  accompany  and  engender  insan- 
ity; and  of  having  pointed  the  way  to  such  as  followed  the  moral,  speculative, 
and  metaphysic  methods  of  observation. 

During  the  last  few  decades  great  activity  has  been  manifested 
in  the  field  of  psychiatric  science,  which  np  to  that  time  had  ])oeii  so 
unfruitful  and  encumbered.  Developing  humanitarian  sentiment 
has  built  institutions  ever3^vhere  favorable  for  the  observation  of  the 
insane ;  and  the  physicians  of  these  asylums,  familiar  with  all  means 
of  diagnosis,  and  schooled  in  the  empiric  method  which  produced 
the  most  brilliant  results  in  the  natural  sciences,  have  everywliere  been 
zealous  to  bring  to  the  service  of  the  new  psychiatry  results  which 
pathologic  anatomy,  physiology,  and  pathology  of  the  nervous  system, 
anthropology,  and  psychophysics  offered.  Flemming,  Jessen,  and  Zel- 
ler  were  successful  workers  in  the  field,  which  had  now  become  purely 
medical  and  somatic.  It  was  the  latter  who  first  gave  currency  to  the 
theory  that  the  various  forms  of  insanity  are  only  stages  of  one  and 


HISTORIC  REVIEW  OF  THE  DEVELOPMENT  OF  PSYOIllA'I'ltY.     45 

the  same  disease-process;  and  it  was  his  celebrated  pupil,  Griesinger, 
whose  epoch-making  text-book  appeared  first  in  1845,  who  first  brought 
together  into  a  comprehensive  theory  all  the  previous  results  of  exact 
scientific  investigation. 

Thus  psychiatry  after  a  severe  struggle  gained  its  rightful  place 
among  the  natural  sciences,  and  freed  itself  from  the  last  clinging 
errors  of  philosophy  and  metaphysics. 

But  much  yet  remains  to  be  attained  before  psychiatry,  which  can 
yet  hardly  lay  claim  to  being  more  than  a  descriptive  science,  can  raise 
itself  to  the  height  of  an  enlightening  science.  Though  here  we  seem 
confronted  with  problems  that  defy  solution  by  human  knowledge,  yet 
in  the  short  period  of  true  scientific  study  to  which  this  domain  has 
been  subjected,  the  results  already  obtained  and  the  unprejudiced 
efforts  of  celebrated  investigators  among  all  civilized  nations  in  the 
various  departments  of  psychiatry  promise  fruitful  progress,  the  most 
immediate  and  attainable  results  of  which  will  be,  at  least  scientifically, 
the  enlargement  of  psychiatry  to  include  the  whole  of  cerebral 
pathology. 

Along  with  the  clinical  method  of  investigation,  which  at  the  present 
time  is  only  too  little  used,  and  which  lias,  for  its  object  of  study,  somatic 
and  especially  the  cerebro-pathologic  phenomena  of  insanity,  thus  becoming 
neurcpathologic  in  its  scope;  and  with  the  biologic  and  anthropologic  methods 
of  study  which  seek  to  solve  the  mystery  of  etiology  and  pathogenesis,  it  is 
anatomic  investigation  which  smooths  the  way  to  an  understanding  of  pa- 
thology and  leads  psychiatry  to  its  goal. 

The  later  anatomico-physiologic  investigation  has,  by  the  discovery  of 
the  lymph-spaces,  by  the  study  of  the  relation  of  the  circulation  of  the  brain, 
of  the  paths  of  innervation  of  its  vessels,  thrown  light  upon  the  circulation 
and  nutrition  of  this  organ.  Unfortunately  chemistry  is  not  yet  able  to  ex- 
plain the  laws  and  products  of  tissue-change.  Experimental  psychology,  rest- 
ing upon  an  exact  psycho-physical  basis,  facilitates  an  understanding  of  the 
psychopathology  of  mental  life;  while  clinical  psychiatry,  resting  upon  the  re- 
sults of  neuropathology  in  general,  seeks  to  investigate  all  the  cerebro-patho- 
logic phenomena  of  insanity  by  means  of  exact  clinical  observation,  aided  by 
all  the  means  at  command.  And  it  seeks  finally,  with  a  view  to  gaining  a 
system  of  classification,  the  establishment  of  pictures  of  diseases  that  are 
empirically  genuine. 

Later  investigations  in  experimental  psychology  and  pathology  concern- 
ing the  relation  of  processes  of  movement,  perception,  secretion,  temperatiu'e, 
and  vascular  innervation  to  certain  limited  areas  of  the  cerebral  cortex,  are 
possibly  of  the  greatest  significance  for  the  science  of  psychiatry.  While,  on 
the  one  hand,  they  justify  the  conclusion  that  diffuse  disease  of  the  cerebral 
cortex  is  necessary  in  order  to  induce  psychoses,  they  at  the  same  time  make 
it  clear  how  certain  elementary  psychic  disturbances  may  exist  as  evidences  of 
loss  or  irritation,  though,  as  a  whole,  the  psychic  functions  are  intact;  just  as 
functional  focal  manifestations  may  co-exist  (aphasia,  mental  blindness,  iso- 


4G  INTRODUCTION  TO  THE  STinV  OF  PSYCHIATRY. 

lated  hallucinations,  etc.).  Even  cfTorts,  to  a  certain  degree  justified,  to  locale 
certain  psychopathic  phenomena  are  not  wanting.  Thus,  Wernike  ("Uebcr  den 
wissenschaftlichen  Standpunkt  in  der  Psydiiatrie,"  ISSO)  explains  dementia  of 
the  paralytic  by  a  summation  of  the  progressive  loss  of  memory-pictures  and 
motor  images  in  tlie  various  sensory  and  motor  centers  of  tlie  shrinking  cortex 
(symptoms  of  loss).  The  motor  disturbances  are  explained  as  the  loss  of 
ideas  of  movements.  Somewhat  venturesome  is  the  exphuiation  of  grand  delu- 
sions as  "a  state  of  irritation  in  the  area  of  those  memory-pictures  which  con- 
stitute personality."  We  may  entertain  the  explanation  that  the  incoherence, 
(■onfusion,  lack  of  orientation,  and  reactional  and  emotional  states  wliich  are 
manifested  by  the  patient  aftiicted  with  acute  delusional  insanity  and  delirium, 
are  referable  to  incongruence  of  memory-pictures  and  impressions  from  the 
external  world  as  a  result  of  abnormal  changes  in  their  physical  substratum: 
/.c,  the  ganglion-cells.  In  the  light  of  tiie  latest  cortical  physiology,  hallucina- 
tions appear  to  be  the  result  of  irritative  processes  in  tlie  corresponding  sen- 
sory centers  (Wernike,  Tamburini,  and  Westphal) ;  and  the  impulse  to  move- 
ment in  the  maniac,  to  be  the  result  of  irritation  of  the  motor  centers  of  the 
forebrain  (Wernike).  Crichton  Browne  (Brain,  October,  1880)  even  explains 
the  predominating  movement  of  certain  gioups  of  muscles  in  the  maniac  as  a 
result  of  irritation  of  corresponding  motor  centers  consequent  upon  regional 
hyperemia^ 

Unfortunately,  the  uncertain  results  of  pathologico-anatomic  inquiry  do 
not  enable  us  to  bring  the  disease-pictures  into  relation  with  pathologic  and 
anatomic  findings,  and  thus  do  not  allow  us  to  replace  symptomatic  by  patho- 
logic and  anatomic  terms. 


BOOK  IL 

General  Pathology  and  Therapy  of  Insanity. 


PART  FIRST. 

Elementary  Anomalies  of  the  Cerebral  Functions 

in  Insanity» 


Clinical  investigation  of  the  complicated  psychopathic  condi- 
tions whicli  form  the  subject  of  special  pathology  in  the  so-called  forms 
of  insanity  requires,  first,  the  study  of  elementary  disturbances,  which 
in  their  sumimation  and  interaction  give  rise  to  the  special  forms  of 
mental  disease.  In  the  foreground  we  find  psychic  anomalies,  which, 
by  reason  of  their  prominence,  bring  about  the  autonomous  position 
of  psychiatry  in  the  domain  of  cerebral  pathology. 

The  study  of  these  elementary  psychic  disturbances,  however,  is  not  of 
value  simply  for  the  understanding  of  the  abnormal  processes  in  insanity, 
M'here  they  appear  in  numbers  and  in  the  guise  of  well-marked  disease-pictures; 
but  it  is  also  important  for  the  general  pathology  of  the  central  nervous  sys- 
tem, since  they  occur  singly  and  temporarily  in  the  clinical  picture  of  other 
cerebral  and  nervous  diseases  which  in  the  narrower  sense  are  not  regarded 
as  psychic. 

This  is  especially  true  of  hallucinations  and  illusions,  of  disturbances  in 
the  reproduction  of  ideas,  of  their  formal  flow  and  their  apperception,  and  of 
manifestations  of  abnormal  emotional  excitability.  Clinical  psychiatry  must 
not,  however,  limit  itself  to  the  study  of  psychic  phenomena  of  insanity,  for  in 
many  cases  the  important  point  in  diagnosis,  prognosis,  and  pathogenesis  lies 
not  so  much  in  these  as  in  disturbances  of  motor,  sensory,  and  vasomotor 
functions. 

In  accord  with  the  functional  significance  of  the  brain  as  the 
central  organ  of  psychic,  sensory,  sensorial,  motor,  vasomotor,  and 
trophic  functions,  we  find,  as  expressions  of  the  fundamental  cerebral 
diseases,  quite  as  many  groups  of  elementary  disturbances  which  must 
form  the  subject  of  clinical  investigation;    and  in  addition  to  these 

(47) 


48  CENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tlicre  are  certain  disturbances  of  the  vegetative  functions  of  nutrition, 
excretion,  respiration,  circulation,  and  body-temperature  ^\liicli  must 
be  taken  into  account,  and  ^vhich,  mediately  or  immcdiateh',  are  in- 
duced by  disease  of  the  psychic  organ. 


CHAPTER  I. 
Elementary  Psychic  Disturbances.    Classification. 

TiiE  great  variety  of  phenomena  presented  in  normal  and  a1)nor- 
mal  mental  activity  demands,  first,  a  general  view  and  classiiication. 
Division  of  the  subject  in  accordance  with  the  three  fundamental  direc- 
tions in  which  psychic  activity  manifests  itself  outwardly  seems  the 
most  natural,  and  in  accordance  with  this  we  may  differentiate : — • 

I.  Phenomena  of  the  affective  side  of  mental  life:  emo- 
tional states  and  emotional  activities. 
II.  Phenomena  in  the  intellectual  sphere,  which,  for  the 
most  part,  comprehend  all  that  falls  under  under- 
standing, reason,  memory,  and  imagination. 
III.  Phenomena  of  the  psychomotor  side  of  mental  activity: 
impulses  and  the  will. 

Thus  we  speak  of  anomalies  of  feeling,  thinking,  and  willing. 
This  division,  however,  has  only  a  didactic  meaning,  and  thus  it  does 
not  lead  us  into  the  error  of  the  older  metaphysic  psychology,  which 
in  this  triad  saw  isolated  and  independent  spiritual  powers,  and 
thereby  fell  into  the  grossest  errors  (monomanias,  partial  insanities). 

Empiric  psychology  recognizes  mind  only  as  a  unit  in  which  the 
various  faculties  present,  in  solidarity  and  united  activity,  only  aspects 
of  psychic  activity  which  are  especially  prominent. 


CHAPTER  II. 
Elementary  Psychic  Disturbances.     Anomalies  of  Feeling   (Emotions). 

Clinical  experience,  which  in  the  majority  of  cases  of  insanity 
teaches  that  the  disturbance  does  not  primarily  arise  in  false  judgment, 
delusions,  and  errors  of  the  senses,  but  in  abnormal  feelings  and  affects, 
leads  first,  then,  to  a  study  of  the  anomalies  of  the  emotions.  These 
may  be,  in  general,  divided  into  abnormal  alterations  of  the  content 
of  the  emotions,  and  abnormalities  of  the  formal  occurrence  of  the 
emotions,  especially  such  as  are  manifest  in  emotional  impression- 
ability. 


ELEMENTARY  ANOMALIES  OF  THE  CEREßRAL  FUNCTIONS.      49 

1.  Anomatjes  in  Content.     Abnormal  States  of  Feeling. 

A  state  of  feeling  appears  abnormal  when  it  occurs  spontaneously : 
i.e.,  when  adequate  external  causes  for  its  occurrence  are  wanting. 
Under  such  circumstances  its  origin  is  not  psj^chologic,  but  organic, 
rt  is  the  expression  of  a  disturbance  of  nutrition  in  the  psychic  organ. 

Thus  it  is  at  once  differentiated  from  those  changes  of  feeling 
which  are  physiologic-  and  the  result  of  motive. 

In  insanity  likewise  this  difference  must  be  emphasized.  In  the  insane 
condition  there  are  many  states  of  feeling  which,  though  induced  by  abnormal 
causes,  are  in  themselves  not  pathologic,  but  the  natural  reaction  to  these 
causes:  thus,  for  example,  a  person  suffering  with  delusions  of  persecution 
hears  voices;  therefore  he  concludes  that  he  is  a  villain,  that  his  life  is 
threatened,  and  he  is  thereby  depressed.  The  delusional  maniac,  the  para- 
lytic, and  the  delirious  patient  have  delusions  of  grandeur  and  corresponding 
hallucinatory  ide^s,  and  thus  experience  expansive  feelings  and  an  increased 
sense  of  self.  On  the  other  hand,  when  such  a  patient  does  not  react  in  this 
way  it  is  pathologic,  and  indicates  great  deterioration  of  the  mind. 

These  reactive,  depressive,  and  expansive  feelings  in  the  insane,  however, 
must  not  be  confounded  with  the  primarily  spontaneous,  motiveless,  and  there- 
fore abnormal  feelings  of  the  emotional  insane  (melancholia,  mania).  The 
feelings  manifested  by  sane  persons  are  found  in  the  insane. 

Practically,  states  of  painful  and  joyful  feeling  present  them- 
selves for  consideration. 

(a)  A  painful,  depressed  state  of  feeling  (psychalgia,  phrenal- 
gia),  that  has  arisen  spontaneously  and  exists  independently,  is  the 
fundamental  phenomenon  in  the  melancholic  states  of  insanity.  Here 
we  have  a  phenomenon  analogous  to  that  which  occurs  in  a  sensory 
nerve  as  a  result  of  disturbance  of  nutrition,  in  the  form  of  neuralgia. 
Disturbance  of  nutrition  in  the  cerebral  cortex  leads  to  mental  pain 
(psychic  neuralgia). 

While,  to  the  nerve  affected  with  neuralgia,  consciousness  reacts 
simply  in  the  form  of  a  general  feeling  (pain),  the  result  is  more  com- 
plicated when  the  organ  of  consciousness  itself  is  diseased.  Owing  to 
the  solidarity  of  psychic  phenomena,  other  anomalies  necessarily  follow 
from  the  primary  elementary  disturbance. 

Thus  to  the  organic  psychic  pain  are  added  other  psychologic 
phenomena. 

An  important  source  of  pain  is  found  in  the  impress  made  upon 
the  depressed  consciousness  by  the  external  world.  The  manner  in 
which  we  react  to  external  impressions  is  entirely  dependent  upon  our 
general  state  of  feeling  and  sense  of  self.  One  and  the  same  event 
has  a  different  effect  upon  us  whether  we  are  depressed  or  exalted. 


r,0  GEN" KRAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  same  landse'ape  iiulucrs  iu  us  entirely  dillVreut  ciiiütions— indeed, 
ajjpears  to  us  with  a  different  coloring — if  our  mood  be  one  of  joy 
or  sorrow.  This  physiologic  law  holds  good  also  under  pathologic 
conditions. 

To  the  melancholic  llio  external  world  seems  somber  and 
changed — in  other  colors;  even  objects  which  under  other  conditions 
would  give  rise  to  pleasant  impressions  seem  now,  in  the  mirror 
of  his  abnormally  changed  sense  of  self,  to  be  M'orthy  of  aversion 
(psychic  dysesthesia). 

A  furtlior  source  of  psychic  pain  lies  in  the  fact  that  the  intellect 
is  under  the  impelling  influence  of  feelings,  and  only  such  ideas  as  are 
in  harmony  with  the  state  of  the  emotions  can  be  entertained  in  con- 
sciousness. 

Owing  to  this  law,  the  melancholic  is  unable  to  retain  in  con- 
sciousness any  other  than  painful  and  depressed  images  and  ideas. 
The  immediate  result  of  this  is  monotony  of  thought  and  consequent 
weariness. 

Along  with  the  melancholic  depression,  the  formal  activity  of 
the  process  of  thought  is  also  hindered,  and  there  is  therefore  a 
notable  inhibition  of  the  psychomotor  aspect  of  the  mind. 

This  inhibition  of  the  will,  this  opposition  to  the  expenditure  of 
psychic  force,  brings  about  a  great  increase  in  the  feeling  of  depres- 
sion, which  is  further  augmented  by  the  fact  that  the  patient  feels  him- 
self overpowered  by  the  disturbance  of  his  ])syehic  mechanism,  and 
powerless  to  resist  it. 

At  the  height  of  the  disease  another  important  source  of  mental 
pain  is  added,  in  that  the  patient  realizes  that  his  ideas  are  no  longer 
colored  by  the  usual  feelings  of  pleasure  or  pain  ;  that  he  can  no  longer 
take  delight  in  or  worry  about  anything  (psychic  anesthesia).  Thus, 
all  kinds  of  stimuli  are  without  effect  upon  him. 

Since  the  disturbance  of  nutrition  is  general,  along  with  the 
psychic  neurosis,  there  are  various  sensory  disturbances  (neuralgias, 
paralgias,  paresthesias,  anesthesias,  and  a  changed  state  of  general  feel- 
ing) ;  the  vegetative  functions  and  muscular  tone  suffer  as  well.  The  e 
multifarious  disturbances  of  the  general  state  of  feeling  form  another 
and  fruitful  source  of  psychic  pain  in  the  depressed  consciousness.  If 
the  latter  elements  of  painful  feeling  predominate,  the  depression 
takes  on  hypochondriac  features.  The  abnormal  painful  depression 
is  in  itself  objectless.  In  the  milder  and  more  transitory  cases  of  this 
kind  it  remains  so,  and,  as  a  rule,  is  recognized  by  the  individual  as 
abnormal.  As  the  disease  progresses  and  the  disturbance  of  conscious- 
ness increases  the  patient  seeks  to  explain  his  depression ;  and,  since  it 


ELEMENTARE  ANOMALIES  OP  THE  CEJtEßllAL  FUNCTIONS.       HI 

is  most  natural  for  him  to  find  the  cause  of  it  in  anything  (external 
world;,  earlier  experiences,  etc.)  rather  than  in  an  affection  of  his 
central  nervous  system,  he  at  last  finds  false  motives  for  it  (vide 
"Delusions").  In  case  of  hypochondriac  depression  dependent  upon 
the  disturbance  of  general  bodily  feeling,  resulting  from  organic 
anomalies,  the  effort  to  find  an  objective  cause  is  made  very  early,  for 
in  such  cases  the  comprehension  of  relations  to  the  external  world  is 
unclouded,  and  then  the  patient  develops  false  ideas  concerning  his 
bodily  condition,  and  is  apt  to  imagine  that  he  is  afflicted  with  organic 
and  incurable  diseases,  when  he  is  subject  only  to  functional  dis- 
turbances. 

(b)  A  state  of  abnormal  gaiety  of  feeling  (amonomania,  psychic 
hedonia — Emminghaus),  analogous  to  which  are  physiologic  pleas- 
ure and  that  induced  by  toxic  agents  (alcohol,  laughing-gas,  etc.),  is 
the  emotional  foundation  of  maniacal  conditions,  and  the  opposite 
of  melancholic  depression.  As  a  result  of  inner  organic  changes  the 
sense  of  self  becomes  pleasurable  and  expansive,  and  the  psychic 
organ  is  capable  of  entertaining  only  pleasurable  emotions. 

In  this  state  this  tone  of  feeling  affects  all  impressions  coming 
from  the  outer  world  as  well  as  all  sensations  derived  from  the 
organism;  in  consciousness  there  are  only  such  images  and  thoughts 
as  are  in  harmony  with  the  emotional  state,  the  activity  of  thought 
is  facilitated,  its  content  is  richer  and  more  changeable,  and  the 
transformation  of  ideas  into  desires  and  actions  is  uninhibited,  in- 
deed, even  facilitated. 

At  the  same  time  the  patient  is  at  every  moment  conscious  of  the 
greater  ease  and  rapidity  with  which  he  thinks  and  acts,  and  the 
amount  of  pleasure  he  derives  from  this  condition  is  comparable  in 
degree  to  that  of  the  pain  experienced  by  the  melancholic  patient. 

2.  Anomalies  (Formal)  in  the  Okigin  of  Emotions  (Abnoemal 
Emotional  Eeaction). 
The  disturl3ances  under  this  head  are,  in  general,  those  related  to 
the  impressionability  of  the  emotions — anomalies  in  the  intensity  of 
emotional  reaction  and  in  the  quality  of  feeling. 

(A)  Anomalies  of  Emotional  ImpressionahiUty. 
With  reference  to  the  impressionability  of  the  emotions,  and  their 
power  to  color  percepts  and  memory-pictures  with  feelings  of  pleasure 
or  pain,  there  are  two  possibilities:  emotional  reaction  occurs  with 
abnormal  ease;  the  threshold  of  excitability  to  emotional  stimuli  lies 
deeper  than  in  normal  life,  so  that  the  latter  are  induced  with  great 
difficulty  or  not  at  all. 


52  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(a)  States   of   Abxük.mally    Increased   K-motiunal   I.mi'ues- 

SIONABILITY     (PSYCHIO     HYPERESTHESIA,     EMOTIONALITY).  —  These 

states  are  alwa3-s  the  expression  of  a  cerebral  condition  characterized 
by  great  loss  of  tone  dependent  upon  interference  with  nutrition, 
bordering  more  or  less  upon  exhaustion,  and  a  manifestation  of  func- 
tional -weakness.  In  its  severest  form  this  emotional  weakness  is 
shown  in  the  fact  that  tlie  slightest  thought  is  associated  with  emo- 
tional reaction.  This  emotional  reaction,  however,  is  not  necessarily 
deep.  In  contrast  with  the  emotional  reaction  of  the  robust  brain 
the  phenomenon  does  not  tarry  long  in  consciousness.  The  short 
duration  of  the  emotional  process  is  explained  in  part  by  the  rapid 
exhaustion  for  a  special  quality  of  feeling  (irritable  weakness),  in  part 
by  the  fact  that  the  image  as  a  cause  of  concrete  feeling  is  quickly 
forgotten,  and  finally  because  it  is  cro^\•dcd  out  by  a  new  idea. 

With  continuance  of  this  abnormal  increased  impressionability 
of  the  emotions  the  mood  is  constantly  changing,  and  with  each  new 
idea  a  related  and  adequate  state  of  feeling  is  induced.  This  irritable 
weakness,  this  emotionality^  is  a  very  prominent  phenomenon  in  per- 
sons with  weakened  brains  convalescing  from  severe  sickness,  like 
typhus  or  typhoid;  in  those  hereditarily  or  otherwise  neuropathic; 
in  the  hysteric,  hypochondriac,  and  neurasthenic;  and  in  certain  or- 
ganic brain  diseases  (dementia  senilis,  dementia  apoplectica,  and  de- 
mentia paralytica,  and  lues  cerebralis — in  their  earlier  stages). 

The  significance  of  this  symptom  as  a  manifestation  of  lessened 
inhibitory  activity  of  the  most  highly  organized  centers  is  shown  also 
by  the  lively  mimetic,  motor,  vasomotor,  and  secretory  disturbances 
which  accompany  the  psychic  trouble.  The  emotional  weakness  is 
expressed  clinically  in  the  sensitiveness  of  these  patients;  in  the  ease 
with  which  weeping  and  laughing  are  induced,  especially  in  the  hys- 
teric, where  it  may  go  to  the  extent  of  becoming  actually  convulsive. 
In  content  these  emotional  states  are  either  pleasurable  or  painful 
(psychic  hyperhedonia  and  hyperalgia — Emminghaus).  In  accord- 
ance with  the  character  of  ideas  which  give  rise  to  the  feelings  in 
question  the  following  may  be  dift'ereutiated :  1.  Sensorial  hyper- 
esthesias: (a)  percepts  derived  from  the  external  world  or  from  the 
body  itself  which  are  associated  with  painful  feelings  (as  in  the 
hysteric,  hypochondriac,  melancholic,  and  those  sick  with  fever)  or  (b) 
with  pleasurable  feelings  (increased  pleasure  in  eating  and  drinking 
and  feeling  of  euphoria  in  mania).  2.  Esthetic  hyperesthesia:  (a) 
feeling  of  displeasure  excited  by  the  ugly  in  art,  by  ugly  faces,  bad 
conduct,  uncleanlincss  of  surroundings,  etc.,  and  (b)  the  opj^osite,  as 
intensified  feelings  of  pleasure  in  art,  persons,  and  things,  and  conse- 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       53 

quent  sympathies,  antipathies^,  and  idiosyncrasies.  3.  Ethic  h3^per- 
esthesias:  (a)  exaggerated  sympathy  in  the  misfortune  or  good  for- 
tune of  others,  violent  aversion  to  what  is  ordinary  and  enthusiasm 
for  heroic  acts;  (h)  with  reference  to  the  feeling  of  self — extraor- 
dinary emotional  reaction  as  a  result  of  insult  or  compliment,  the 
ready  occurrence  of  sympathy  and  enthusiasm  as  the  result  of  ade- 
quate ideas,  and  increased  sensibility  to  a  sense  of  shame,  even  to  the 
extent  of  prudery  (certain  hysteric  individuals). 

(h)  States  in"  v^^hich  it  is  Difficult  to  Excite  Emotional 
Eeaction  (Emotional  Dullness). — Complete  lack  of  emotional 
reaction  or  its  diminution  in  the  presence  of  adequate  impressions  is 
a  frequent  and  important  elementary  symptom  (psychic  anesthesia). 
It  may  be  either  a  phenomenon  of  inhibition  or  it  may  indicate  a  loss 
in  the  psychic  mechanism.  This  difference  is  of  great  clinical  and 
prognostic  importance.  An  important  differential  sign  lies  in  ascer- 
taining whether  the  patient  is  conscious  of  his  emotional  loss  and  is 
painfully  affected  by  it  (anesthesia  psychica  dolorosa). 

The  latter  is  generally  the  case  in  melancholies.  In  melancholia 
the  psychic  anesthesia  is  a  result  of  inhibition.  The  inhibition  of 
pleasurable  feelings  is  the  result  of  the  abnormal  and  organically  fixed 
painful  depression,  and  at  the  height  of  the  disease,  at  least,  the  feel- 
ings are  also  blunted  to  impressions  which  are,  in  themselves,  painful. 
The  reason  for  this  lies  in  the  marked  blunting  effect  of  the  spon- 
taneous psychic  pain  as  a  result  of  which  external  painful  impressions 
seem  too  Aveak  to  bring  about  their  normal  effect.  We  sometimes  see 
the  same  thing  in  states  of  violent  physiologic  depression,  where,  as  a 
result  of  preponderance  of  painful  impressions,  a  state  of  dullness  and 
indifference  occurs  in  which  the  sufferer — temporarily,  at  least, — 
remains  imaffected  by  any  new  painful  event. 

The  lack  of  ethic  and  religious  emotional  feeling  in  melancholia 
is  of  special  importance.  It  is  expressed  in  indifference  toward  those 
things  which  are  otherwise  held  to  be  of  the  highest  importance : 
religion,  family,  occupation,  friends,  and  social  duties.  The  patients 
are  painfully  depressed  by  this,  and  begin  to  doubt  whether  they 
are  human  beings,  because  they  no  longer  feel  as  human  beings  feel. 
The  want  of  religious  support  and  the  comfort  afforded  in  prayer  is 
felt  to  be  especially  painful.  These  inhibitory  phenomena  may  be- 
come the  substratum  for  later  zoanthropic  and  demoniacal  delusions. 

In  another  class  of  abnormal  psychic  states  the  lack  of  feeling  is 
partly  inhibitory  and  partly  a  manifestation  of  actual  loss.  Emotional 
coloring  may  be  wanting  in  all  domains  of  thought  or  only  in  the 
ethic  sphere. 


54  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Thus,  in  the  maniac  tliere  is  a  renin rkable  lack  of  interest  in  the 
ethic  relations  of  life  and  duties.  It  points  to  a  lack  of  that  moral 
and  esthetic  feeling  which  he  once  had,  and  it  is  partly  explained 
by  the  falsification  of  consciousness  by  pleasurable  feelings ;  partly  by 
the  impossibility,  owing  to  the  compelling  force  of  the  emotional  state, 
of  entertaining  opposing  ideas  of  danger,  immorality,  and  threatened 
punishment,  with  its  accompanying  feeling  of  pain;  partly  by  the 
rapidity  of  all  psychic  processes,  which  prevents  the  entertainment  of 
an  idea,  and  also  the  consideration  of  tlie  significance  of  an  event 
or  act. 

In  insanity  with  systematized  delusions  (paranoia)  the  delusions 
which  falsify  the  consciousness  of  the  patient  inhibit  the  perception 
of  former  interests  and  relations.  Out  of  his  new  and  abnormal  ego 
lie  looks  upon  his  healthy  past  as  something  foreign  and  unrelated 
lo  himself.  In  many  patients  of  this  kind,  as  a  result  of  the  concrete 
content  of  their  delusions  (persecutory  ideas),  an  unfriendly  rela- 
tion to  the  external  world  arises,  and  interest  in  the  welfare  or  sufi'ering 
of  others  is  greatly  changed.  On  the  other  hand,  within  the  circle 
of  the  delusion  with  which  he  is  occupied  the  patient  is  full  of  feeling 
and  very  excitable.  However,  in  the  course  of  time  emotional  reaction, 
even  to  delusions,  may  disappear:  a  sign  of  a  state  of  mental  weak- 
ness', of  loss  in  the  psychic  mechanism. 

Much  more  frequently  emotional  dullness  is  observed  as  a  symp- 
tom of  actual  loss  in  the  mental  sphere  in  psychopathic  conditions. 
In  all  cases  of  psychic  weakness  it  has  this  important  diagnostic  and 
prognostic  meaning.  It  is  only  one  of  the  signs  of  general  dullness 
and  insufficiency  of  the  psychic  activities.  Since  this  loss  of  that 
which  gives  value  to  the  man  cannot  be  realized  by  the  patient,  it  is 
not  accompanied  by  painful  feeling.  This  reduction  of  emotional 
excitability  is  the  cause  of  the  lack  of  interest  which  the  majority  of 
insane  patients  feel  in  the  lot  of  their  relatives  and  companions,  and 
at  the  same  time  a  reason  why  they  are  so  easily  diverted. 

The  emotional  dullness  of  these  psychic  invalids  presents  many 
degrees  of  intensity,  and,  owing  to  the  richness  of  the  emotional  life, 
various  losses  in  its  nniltifarious  aspects. 

Defect  in  the  ethic  domain  is  the  most  important. 

It  is  interesting  to  note  that  it  is  often  found  as  the  first  sign  of 
commencing  mental  weakness  due  to  grave  organic  diseases  of  the 
brain  (dementia  paralytica  and  dementia  senilis),  and  it  frequently 
precedes  for  a  long  time  the  occurrence  of  weakness  of  intellect  and 
memory.  Not  infrequently  it  forms  the  only  residuum  of  a  psychosis 
that  has  apparently  ended  in  recovery. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       55 

Such  individuals  return  to  their  former  life  and  may  even  be  capable  of 
leading  their  usual  social  existence;  but,  in  contrast  with  their  former  selves, 
they  have  become  Philistines  and  egotists.  The  v/elfare  and  suffering  of  their 
fellow-men  no  longer  appeal  to  them.  Even  the  old  bonds  of  family  and 
friendship  are  loosened  and  only  maintained  by  habit.  With  this  lack  of  in- 
terest in  all  the  higher  esthetic  and  ethic  relations  of  civilized  life  they  satisfy 
their  material  needs  and  perform  their  duties. 

That  this  defect  in  emotional  sensibility  is  often  the  first  manifestation 
of  an  advancing  state  of  mental  weakness  is  explained  by  the  fact  that  the 
ethic  feelings  (pity,  honor,  religious  sentiment),  in  so  far  as  they  have  their 
roots  in  the  development  and  application  of  ethic  ideas  and  concepts,  are  the 
products  of  the  highest  mental  activity,  calling  for  the  finest  brain  organiza- 
tion, and  therefore  they  are  the  first  to  suffer  when  the  psychic  organ  becomes 
diseased. 

A  similar  condition  of  abnormal  lack  of  moral  sensibility  is  often  de- 
veloped for  like  causes  in  onanists  and  spirit-drinkers. 

It  may  also  be  congenital,  for  the  most  part  as  an  anomaly  having  its 
foundation  in  hereditary  degenerative  factors;  and  it  may  then  be  called 
moral  idiocy,  since  the  brains  of  such  unfortunates,  as  a  result  of  degenerate 
influences  affecting  the  embryo  itself,  are  endowed  with  an  inferior  organiza- 
tion, which  robs  them  of  the  capability  of  forming  esthetic  and  ethic  ideas 
and  combining  these  into  ethic  concepts.  In  such  cases  Schule  ("Handbook," 
page  46)  differentiates  the  graver  conditions,  in  which  moral  feelings  and  ideas 
are  absolutely  wanting,  from  those  in  which,  tJiough  such  ideas  are  acquired, 
they  cannot  be  excited  because  they  are  never  accompanied  by  emotional 
coloring. 

Among  the  subsidiary  accompaniments  of  this  ethic  defect  there  are  two 
which  merit  mention  because  of  their  practical  forensic  importance:  namely, 
want  of  feeling  of  self  (honor)  and  lack  of  remorse  for  criminal  or  immoral 
acts. 

The  want  of  esthetic  feeling  (esthetic  anesthesia)  in  snch  states 
of  psychic  weakness  explains  and  makes  possible  the  indulgence  in 
disgusting  things  and  the  practice  of  disgusting  habits.  In  the  sexual 
sphere  in  connection  with  moral  anesthesia  it  leads  to  certain  revolt- 
ing perversions  of  the  sexual  impulse,  and  causes  the  indifference 
of  certain  patients  in  the  satisfaction  of  their  sexual  and  physical 
needs. 

On  the  other  hand,  it  is  questionable  whether  the  indifference  of 
certain  hypochondriac  and  hysteric  patients  in  the  satisfaction  of  their 
necessities,  the  indifference  with  which  they  speak  of  the  bodily  func- 
tions, is  a  symptom  of  loss  of  esthetic  feeling  or  a  manifestation  of 
inhibition;  for  it  is  possible  that  the  intensity  and  force  of  certain 
feelings  and  ideas  may  prevent  activity  of  opposing  concepts. 

Inhibition  or  loss  of  ethic  and  esthetic  feelings  necessarily  leads 
to  egotism,  and  this  explains  the  frequency  of  this  anomaly  in  the 
insane,  and  why  the  majority  of  them  are  actually  egotists. 


56  GENEUAL  PATIIOLOdY  AND  THERAPY  OF  INSANITY. 

(B)  Anomalies  in  the  Intensiiy  of  Emotional  Reaction. 

Abnormal  intensity  of  emotional  reaction  exists  when  the  emo- 
tion accompanying  an  idea  reaches  the  intensity  of  an  affect,  while 
nnder  physiologic  conditions,  with  the  same  cause,  the  idea  would 
be  associated-  only  with  feelings.  Affective  states  that  are  char- 
acterized by  unusual  duration  and  intensity,  extending  even  to  a 
degree  which  brings  about  loss  of  consciousness  or.  complete  con- 
fusion of  the  intellect  {vide  "Pathologic  Affects" — transitory  insan- 
ity), are  to  be  regarded  as  especially  grave  signs  of  functional  disturb- 
ance of  the  emotions,  representing,  so  to  speak,  convulsive  reaction  of 
the  psychic  organ.  A  state  of  psychic  hyperesthesia  facilitates  the 
occurrence  of  abnormally  intense  (emotional)  reaction;  but  the  pleas- 
urable and  depressive  affects  of  dements,  especially  those  that  are 
angr}',  owing  to  their  great  intensity,  which  depends  upon  absence  of 
all  inhibition,  show  that  this  is  not  a  necessary  accompaniment.  It 
is  only  ethic  and  esthetic  affects  that  are  impossible  in  such  patients. 
Essentially,  the  intensity  of  emotional  reaction  is  referable  to  the  loss 
of  inhibitory  central  influences, — psychically,  to  tbe  functional  weak- 
ness of  the  highest  mental  sphere;  somatically,  to  the  defective  inhi- 
bition of  vasomotor  and  motor  centers  implicated  in  the  emotional 
process, — and  in  consequence  the  resulting  organic  activity  becomes 
especially  powerful. 

There  are  individuals  in  whom  there  is  habitually  an  abnormal 
emotional  instability.  Formerly  such  persons  were  regarded  as  offer- 
ing examples  of  a  peculiar  form  of  mental  disease  (excandescentia 
furibunda  or  iracundia  morbosa),  while  in  reality  they  are  only  exam- 
ples of  an  elementary  affective  disturbance,  a  pathologic  mode  of  cere- 
bral reaction.  It  is  always  a  sign  of  grave  disease  of  the  brain.  It 
indicates  a  brain  weakened  by  anemia,  alcoholic  excesses,  or  severe 
shock  (cerebral  diseases,  head  injury)  ;  or  a  brain  affected  with  a  grave 
neurosis  (hereditary  taint,  eiDÜepsy,  hysteria)  ;  or  a  brain  of  defective 
organization  (idiocy).  In  such  conditions  the  slightest  cause  leads  to 
the  explosive  affect  of  anger,  which,  owing  to  continued  reproduction 
of  painful  thoughts,  is  maintained  at  its  height. 

The  nature  of  an  affect  is  essentially  dependent  upon  the  content 
of  the  inciting  idea  and  the  simultaneotis  state  of  self-sensibility 
and  self-feeling.  If  this  feeling  be  painful  and  the  feeling  of  self 
diminished  (melancholia),  then  the  emotional  reaction  or  the  corre- 
sponding affect  can  be  only  painful.  Under  such  circumstances 
memory-pictures  and  sensory  perceptions,  derived  either  from  the 
external  world  or  from  the  body  itself,  are  sufficient  to  induce  this 
^motional  reaction. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       57 

Moreover,  ideas  which  physiologically  excite  pleasure  under  such 
circumstances  are  capable  only  of  exciting  painful  affects.  At  the 
height  of  the  disease  every  psychic  process,  even  mere  sensory  per- 
ception, induces  such  emotional  states  (psychic  hyperesthesia);  just 
as  a  nerve,  the  irritability  of  which  normally  lies  deep,  when  affected 
with  neuralgia  reacts  with  painful  paroxysms  to  mechanical,  thermic, 
and  atmospheric  stimuli  that  otherwise  would  be  without  effect.  ISTot 
infrequently  such  states  of  psychic  hyperesthesia  are  accompanied  by 
conditions  of  sensorial  and  sometimes  cutaneous  hyperesthesia. 

Affects  are  simply  painful  (sadness,  despair),  surprising  (embar- 
rassment, confusion,  astonishment,  and  shame),  or,  most  frequently, 
expectant  (anxiety,  fear). 

In  states  of  pleasurable  sensibility  and  expansive  feeling  of  self 
(mania)  the  disturbance  is  manifested  in  joyous  affects,  under  circum- 
stances where  normally  only  pleasurable  feelings  would  be  manifested. 

In  these  cases,  too,  at  thö  height  of  the  disease,  phases  are  met 
in  which  there  is  a  condition  of  true  psychic  hyperesthesia,  in  so  far 
as  every  thought  and  even  perception  is  associated  with  an  affect,  and 
the  patient  lives  in  a  continued  state  of  joyful  emotion  (hyperhedonia 
— Emminghaus;   hypermetamorphosis — ISTeumann).     ' 

If  the  feeling  of  self  is  not  depressed,  and  the  idea  provoking  the 
affect  is  one  associated  with  painful  feelings,  then  the  resulting  affect 
is  the  so-called  mixed  affect  of  anger. 

In  this  state  of  angry  feeling  the  slightest  causes — a  glance,  a 
gesture,  even  a  kind  word — may  suffice  to  induce  repeated  explosions 
of  anger  in  the  sensitive  patient. 

(C)  Anomalies  in  the  Quality  of  Emotional  Coloring. 

There  are  abnormal  states  of  feeling  in  which  the  concrete  idea 
is  no  longer  accom]3anied  by  the  physiologic  emotional  coloring  or  that 
previously  characteristic  of  the  individual,  but  by  another  state  of  feel- 
ing, which,  under  some  circumstances,  may  be  the  exact  opposite  of 
that  which  should  normally  occur  (perversion  of  feeling,  paralgia- — • 
Emminghaus — analogous  to  the  abnormal  reaction  of  sensory  nerves) . 

This  anomaly  rests  upon  the  assumption  that  notwithstanding 
the  old  saying,  "de  gustibus"  certain  impressions  under  normal  cir- 
cumstances produce  like  emotional  reaction  in  different  individuals. 
Here  we  are  dealing,  not  with  a  loss  of  certain  normal  emotional 
reactions,  as  in  cases  of  emotional  dullness,  but  with  reactions  that  are 
in  contrast  with  those  which,  in  accordance  with  experience,  are  normal 
to  the  individual  and  to  mankind  in  general.  For  this  reason,  per- 
verse colorings  of  the  emotions  more  readily  and  clearly  appear  abnor^ 


5S  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

mal  than  do  anomalies  of  impressionability  and  intensity  of  reaction. 
They  are  of  the  greatest  practical  importance,  because  they  easily 
become  associated  with  an  impulse  -which  may  lead  to  acts  which  are 
injurious  to  the  interest  of  the  individual  as  well  as  to  the  interest  of 
society. 

Among  the  perverse  reactions  in  the  sphere  of  sensory  feeling 
the  idiosyncrasies  of  neuropathic  and  especially  hysteric  persons  may 
be  given  as  examples;  for  whom  physiologically  pleasant  sensations 
(the.  odor  of  aowers,  etc.)  may  be  experienced  as  unpleasant,  and 
unpleasant  odors  as  pleasant.  As  an  example  of  motor  reaction  we 
have  so-called  pica  (cravings). 

As  a  rule,  associated  with  this  perversion  of  sensation  there  is 
sensorial  and  psychic  hyperesthesia  (facilitated  impressionability  and 
abnormally  intense  reaction,  psychically  reaching  the  degree  of  violent 
affects,  and  somatically  the  degree  of  convulsions). 

Pleasure  in  the  pain  of  men  and  animals,  with  the  consequent 
inclination  to  torture  human  beings  and  animals,  to  destroy  and  pro- 
fane monuments  of  art  and  religion,  is  the  corresponding  perversion 
in  the  sphere  of  ethic  feeling.  It  is  frequently  associated  with 
anomalies  of  sexual  feeling,  the  somatic  root  of  ethic  and  social  feeling. 

As  belonging  to  the  same  category,  we  may  mention  aversion  to 
work  and  to  married  life;  pleasure  in  crime  and  inmiorality,  and  in 
the  destruction  of  the  happiness  and  family  life  of  others,  so  frequently 
exhibited  by  those  that  are  psychically  degenerate  (moral  insanity). 
As  a  rule,  these  perversions  are  associated  with  manifestations  of  loss. 

The  coloring  of  ideas  usually  painful  in  themselves  ^^•ith  pleasur- 
able feelings  is  also  to  be  mentioned :  One  of  my  patients  durijig  the 
maniacal  stage  of  folie  circulaire  lost  her  beloved  husband,  and  she 
had  to  make  a  decided  effort  in  order  to  give  the  impression  of  being 
a  mourner.  Melancholic  patients  present  the  opposite  extreme.  They 
likewise  are  in  the  power  of  an  abnormal  emotion,  and  to  impressions 
which  are  normally  attended  with  pleasurable  feelings  they  react  only 
with  pain;  for  example,  in  their  intercourse  with  their  children  and 
acquaintances  to  whom  they  are  bound  by  affection  they  receive  only 
painful  impressions.  This  reaction  may  be  simply  passive  (misan- 
thropv),  or  it  may  even  go  to  the  extent  of  an  unfriendly  attitude 
which  expresses  itself  in  word  and  act. 

Finally,  a  peculiar  perverse  manner  of  feeling  in  melancholies  is 
exemplified  in  the  so-called  pleasure  in  pain  (Ideler,  Emminghaus), 
in  that  ideas  which  are  normally  felt  to  be  painful  call  up  a  feeble 
feeling  of  satisfaction  in  the  depressed  consciousness,  and  thus  the 
color  of  emotions  is  relatively  pleasant. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       59 

CHAPTER  in. 

Elementary  Psychic  Disturbances.     Intellectual  Anomalies. 

Within  the  domain  of  the  intellect  there  are  primarily  two  cate- 
gories of  elementary  disturbances : — 

1.  Disturbances  in  the  formal  activity  of  intellectual  processes. 

2.  Fallacies  in  the  content  of  ideas  (delusions). 

1.  Formal  Intellectual  Disturbances. 

Anomalies  of  this  kind  possess  no  less  importance  than  those 
which  aifect  the  content  of  ideas,  though  by  the  laity  the  latter  are 
regarded  as  of  primary  importance.  Clinically,  and  especially  foren- 
sically,  it  is  to  be  noted  that  disturbances  of  this  kind  may  constitute 
the  entire  intellectual  anomaly  (insanity  without  delusions). 

Formal  anomalies  may  be  classified  as  follows : — 

(A)  Disturbance  of  the  rapidity  of  ideation. 

(B)  Disturbance  of  association  in  so  far  as  certain  kinds  of  association 
predominate. 

(C)  Anomalies  affecting  the  number  of  ideas  in  so  far  as  certain  ideas 
remain  in  consciousness  with  abnormal  intensity  and  duration. 

(D)  Disturbance  of  the  association  of  ideas  with  sense-impressions  (ap- 
perception ) . 

(E)  Disturbance  of  the  reproduction  of  former  ideas   (memory). 

(F)  Anomalies  of  reproduction  of  ideas  in  changed  form  (imagination). 

(A)  Disturbance  of  the  Bapidity  of  I,deation. 

There  are  two  possible  anomalies  of  this  kind:  Ideation  may  be 
abnormally  slow  or  abnormally  rapid. 

(a)  Abnormal  slowness  of  ideation  occurs  in  various  conditions : 
in  melancholia  and  in  states  of  mental  weakness  (dementia).  The 
cause  of  this  in  melancholic  individuals,  on  the  one  hand,  lies  in  the 
fact  that,  owing  to  the  limitation  of  the  content  of  thought  to  painful 
ideas,  only  such  as  are  in  harmony  with  the  state  of  feeling  can  enter 
consciousness;  and,  on  the  other  hand,  in  the  fact  that  in  melan- 
cholies all  the  psychic  processes  are  subject  to  inhibition. 

The  slowing  of  thought  in  melancholia  may  go  to  the  extent  of 
temporary  stagnation,  which  is  reflected  in  consciousness  by  the  feel- 
ing of  interruption  of  thought,  of  becoming  idiotic  and  devoid  of  the 
power  to  think.  Owing  to  this  sluggishness  of  thought,  a  feeling  of 
monotony   necessarily   arises   which   is   the   principal   complaint   of 


GO  GENERAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

many  melancholies.  The  patient  feels  just  as  a  healthy  person  does 
who  is  in  an  emotional  state  of  apprehension.  The  lack  of  variety 
of  thought  in  both  eases  causes  time  to  seem  like  eternity,  and  leads 
to  many  purposeless,  impulsive  acts  which  are  merely  due  to  the  neces- 
sity of  breaking  the  monotony  and  permitting  the  inflow  of  new 
ideas. 

The  slow  thought  in  states  of  mental  weakness  is  but  one  of  the 
manifestations  of  general  weakening  of  the  psychic  energies,  especially 
that  of  memor}»-,  further  conditioned  by  the  lack  of  interest  which 
ordinarily  stimulates  the  processes  of  thought,  and  by  defective  ajjper- 
ception. 

(h)  Increase  in  the  rapidity  of  thought  is  common  to  all  states 
of  mental  exaltation,  and  the  degree  of  rapidity  of  ideation  is  a 
valuable  measure  of  the  intensity  of  the  cerebral  excitement. 

The  milder  degrees  of  this  condition  are  analogous  to  the  ex- 
pansive emotional  state  of  the  sane  and  the  condition  when  wine 
begins  to  loosen  the  tongue,  and  characterize  the  initial  stages  of 
maniacal  exaltation. 

This  is  one  of  the  general  phenomena  due  to  increased  ease  and 
rapidity  of  psychic  processes  as  manifested  in  the  maniacal,  espe- 
cially in  the  sphere  of  memory;  but  in  part  it  is  also  conditioned  by 
the  enlivening  influence  of  the  joyful  feeling  which  exists  in  this  state. 

This  condition  expresses  itself  clinically  in  greater  richness  of 
imagery  and  words,  in  bright  thoughts,  witty  replies,  and  extraordi- 
nary talkativeness,  and  passes  progressively  into  disconnected  flight 
of  ideas. 

In  his  flow  of  words  the  patient  expresses  ideas  entirely  dis- 
connected. The  process  of  association  becomes  unintelligible,  doubt- 
less because  in  the  great  rapidity  of  thought  the  connecting  mem- 
bers of  a  series  of  ideas  cannot  be  expressed,  or  at  least  they  do  not 
enter  consciousness  with  sufficient  clearness  to  find  their  reflex  in 
speech. 

Still  higher  degrees  of  increased  rapidity  of  thought  may  be 
called  flight  of  ideas.  In  this  condition  the  patient  is  no  longer 
able  to  control  his  ideation.  He  passes  from  hundreds  into  thou- 
sands; he  loses  the  thread  of  conversation;  he  is  no  longer  able 
to  arrange  logically  the  abundance  of  material  that  comes  to  him. 
He  expresses  senseless  ideas,  disconnected  sentences,  words,  and  syl- 
lables, if  it  still  be  possible  for  these  to  excite  a  reflex  in  the  mechanism 
of  speech.  TJsnally  in  this  whirl  of  ideas  we  find  at  least  some  threads 
of  association :  the  connection  of  ideas  in  accordance  with  contrast  or 
with  assonance  and  alliteration.     In  this  condition  logical  thought  has 


ELEMENTARY  ANOMALIES  OP  THE  CEREBRAL  FUNCTIONS.       01 

necessarily  come  to  an  end;  and,  since  the  lightning-like  ideas  can  no 
longer  be  co-ordinated  or  placed  in  logical  sequence,  the  result  is 
incoherence. 

Incoherence  of  thought  and  speech  is,  however,  not  exclusively 
the  result  of  increase  in  the  rapidity  of  thought  or  a  symptom 
only  of  maniacal  states.  It  occurs  also  in  various  other  abnormal 
conditions,  and  in  general  under  such  circumstances  it  is  referable  to 
disturbances  of  consciousness,  especially  to  disturbances  of  the  faculty 
of  apperception  and  of  the  association  of  ideas.  Incoherence  or  con- 
fusion is,  moreover,  a  common  phenomenon  in  affective  states,  espe- 
cially where  these  are  manifested  by  a  predisposed  or  weakened  brain. 
In  these  conditions  the  violent  emotional  excitement  calls  into  con- 
sciousness a  multitude  of  contradictory  ideas  and  prevents  their  ready 
apperception,  association,  and  logical  succession.  This  is  especially 
true  for  the  affect  of  embarrassment,  where  the  painful  feeling  of 
uncertainty,  of  danger  of  failure,  disturbs  the  development  of  idea- 
tion and  makes  the  intended  action  or  expression  in  speech  impos- 
sible. 

Confusion  is  an  important  symptom  in  states  of  psychic  exhaus- 
tion. In  these  cases  it  is  to  be  attributed  to  a  functional  weakness  in 
the  logical  combination  of  association,  as  a  result  of  which  the  threads 
of  thought  are  continually  broken,  the  train  of  thought  rendered 
imperfect,  and  often  totally  unrelated  ideas  forced  into  the  mind. 
Of  this  nature,  in  such  delirious  states  of  weakness,  is  the  constantly 
occurring  interruption  of  the  logical  processes  of  thought  by  delusions, 
illusions,  and  hallucinator}^  perceptions,  which  in  themselves  call  up 
chains  of  ideas  that  are  totally  inharmonious.  In  such  states  there 
are  frequently  disturbances  of  consciousness,  especially  of  appercep- 
tion, of  a  peculiar  kind  (mental  blindness  and  mental  deafness).  In 
these  cases  the  perceptive  centers  are  incapable  of  reproducing  previous 
memory-pictures — the  patients  are  absolutely  unorientated  in  the  ex- 
ternal world — or  the  memory-pictures  reproduced  are  incongruent 
with  the  simultaneous  sensory  impressions. 

Incoherence  also  occurs  in  terminal  states  of  mental  weakness, 
where  masses  and  whole  series  of  ideas  have  been  lost;  words  and 
concepts  have  undergone  a  pathologic  transformation,  or  even  new 
words  have  been  formed,  and  chains  of  ideas  that  have  been  fixed  by 
habit  constantly  force  themselves  into  the  process  of  thought. 

In  all  these  cases  the  result  is  insane  speech  and  insane  action; 
both  anomalies,  however,  are  not  necessarily  combined. 

Incoherence  of  speech  may  also  result  from  simple  paraphasia 
and  word-deafness.     Correctness  of  conduct  points  to  the  existence  of 


GO  Oi:XKr!AL  rATllOLOOY  AND  THERAPY  OF  INSANITY. 

thitr.  phenonieiion  of  confused  and  inverted  speech,  with  retained  intel- 
ligence, which  occurs  sometimes  in  some  focal  diseases  of  the  brain. 

Me^Tiert  has  described  a  certain  form  of  confusion  as  pseudo- 
aphasic  confusion :  i.e.,  lack  of  orientation,  as  a  result  of  mental  blind- 
ness and  mental  deafness  with  lessened  ideational  activity  (judgment), 
and  a  feeling  of  anxiety  present  in  the  clouded  consciousness  due  to 
the  kick  of  understanding  of  the  events  in  the  external  world,  asso- 
ciated with  amnesic,  aphasic,  and  paraphasic  phenomena. 

(B)  Disturhances  of  Association. 

Under  this  heading  belongs  the  one-sided  predominance  of  certain 
forms  of  association.  In  insanity  it  may  happen  that  the  process  of 
thought  is  dependent  upon  external  similarity  of  sound — the  similarity 
of  Avords — while  imder  physiologic  conditions  the  ideas  are  called  up 
in  accordance  with  their  content  and  their  causal  relations,  and  asso- 
nance and  alliteration  play  but  an  accidental  and  very  subordinate 
part. 

This  disturbance  of  association,  which  is  most  beautifully  exem- 
plified in  maniacal  states,  may  be  called  a  play  of  syllables.  The 
patient  speaks  in  verses,  which  are,  of  course,  imperfect ;  or  he  strings 
words  together  which  have  no  logical  connection  and  are  only  related 
through  similarity  of  sound. 

One  of  my  maniacal  patients  presented  the  following  association  of  ideas: 
"Ich  lieg'  an  der  Wand,  geben  Sie  mir  die  Hand;  geben  Sie  mir  einen  Kuss, 
imd  da  gibtes  viel  Verdruss;  ich  muss  haben  einen  Sterz,  und  das  Auge  sieht 
himmelwärts;  legen  Sie  die  Hand  auf  mein  Herz!  Ach,  das  macht  mir 
Schmerz." 

Another  abnormal  manner  of  association  is  presented  by  those 
cases  where  a  reproduced  or  apperceived  idea  is  constantly  and  insist- 
ently associated  with  the  question  "Why?" 

The  abnormality  of  this  phenomenon  is  shown  by  the  fact  that 
it  occurs  paroxysmally  and  is  associated  with  other  nervous  symptoms ; 
that  while  it  is  burdensome  to  the  patient,  the  answer  to  the  question 
is  often  entirely  useless  and  related  to  religious  and  metaphysic 
things  which  have  not  the  slightest  interest  for  the  patient. 

Griesinger  was  the  first  to  call  attention  to  this  interesting 
anomaly,  and  he  caHed  it  "Grubelsuclii."  Related  to  this  Meschede 
reported  some  cases  which  he  called  "phrenolepsia  erotematica,"  in 
which  the  patient's  thought  constantly  took  the  form  of  questions  and 
kept  him  constantly  busy  with  prolDlems,  besieging  those  about  him 
with  questions,  but  having  not  the  slightest  interest  in  the  answers. 


ELEIVIENTAIIY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       63 

This  phenomenon^,  which  occurs  almost  exclusively  in  those  pre- 
disposed and  especially  in  individuals  exhausted  by  sexual  excesses, 
forms  the  transition  to  the  following : — 

(C)  Disturbances  in  the  Intensity  and  Duration  of  Ideas. 
Imperative  Ideas. 

There  are  numerous  nervous  and  emotional  patients  who  complain 
of  certain  troublesome,  annoying  thoughts,  the  absurdity  and  irrele- 
vancy of  which  they  perfectly  comprehend,  but  of  which  they  cannot 
rid  themselves.  They  complain  that  these  thoughts  constantly  force 
their  way  into  their  conscious  logical  and  associated  ideas,  disturbing 
the  course  of  them  and  causing  much  annoyance.  Indeed,  such 
thoughts  may  be  associated  with  imj)ulses  to  carry  out  the  correspond- 
ing acts,  which  in  some  instances  the  patients  recognize  as  silly  or 
revolting. 

Such  thoughts,  which  are  fixed  in  consciousness  with  abnormal 
intensity  and  duration,  I  called  "imperative  ideas''  in  1867.  The 
primary  origin  of  an  imperative  idea  is  spontaneous;  it  comes  into 
consciousness  suddenly,  or  it  is  called  up  by  some  violent  external 
event  (murder,  execution,  fire,  suicide  of  some  beloved  person,  etc.). 
Its  formation  in  the  first  case  cannot  possibly  be  due  to  the  psychologic 
awakening  of  ideas  in  the  usual  manner  of  association;  it  must  be 
called  up  and  maintained  by  inner  physiologic  stimuli  affecting  the 
psychic  organ.  Thus  is  explained  its  effect  to  disturb  conscious 
thought  and  its  strange  content  and  irresistible  power  against  the 
energy  of  ordinary  association.  "With  respect  to  their  manner  of 
origin,  these  imperative  ideas  resemble  primordial  delusions  in  con- 
trast with  delusions  formed  psychologically  by  means  of  association 
and  reflection.  They  are  spontaneous,  primary  creations  of  an  abnor- 
mally organized  or  diseased  brain:  the  immediate  product  of  uncon- 
scious thought,  like  the  majority  of  hallucinations  in  the  psycho- 
sensorial  sphere.  These  imperative  ideas  have  analogies  in  certain 
images,  thoughts,  and  musical  motives,  which  under  physiologic  con- 
ditions mix  themselves  in  our  quiet  thinking  and  have  no  relation  to 
our  thoughts,  but  distract  and  annoy  us;  and  they  are  in  some  in- 
stances so  persistent  that  they  can  be  overcome  only  after  considerable 
effort  of  the  will  and  strain  of  the  associative  mechanism. 

Here  we  are  also  evidently  concerned  with  spontaneous  creations 
which  result  from  physiologic  excitation  of  the  ideational  centers ;  for 
the  fact  that  they  do  not  arise  by  way  of  psychic  association  is  proved 
by  their  strange  and  disturbing  content,  and  their  resistance  to  the 
power  of  association.     In  many  cases  the  motive  of  imperative  ideas 


Gi  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

remains  obscure;  in  other  cases  there  are  organic  feelings  and  neu- 
ralgias which  enter  consciousness  simultaneously  and  apparently  in- 
duce the  ideas  and  are  always  sufficient  to  call  them  up.  In  instances 
where  an  external  event  acts  as  a  cause,  we  are  dealing  with  a  central 
organ  that  is  unusually  impressionable;  and  in  this  case  the  phenom- 
enon is  analogous  to  what  we  know  as  an  after-sensation. 

Here,  too,  feelings  of  bodily  discomfort  may  be  coincident;  there 
may  become  associated  with  the  imperative  idea  in  statu  nascenJi 
excitations  of  the  sensory  paths,  and  thus  fix  the  abnormal  idea  in 
consciousness.  These  truly  fixed  ideas,  or  imperative  concepts,  are 
difCerentiated  from  delusions  in  a  strict  sense  by  their  relation  to 
consciousness,  which  invariably  looks  upon  them  as  abnormal  phe- 
nomena, and  thus  stands  apart  from  them. 

The  content  of  these  imperative  ideas  may  be  quite  as  varied  as 
that  of  delusions.  Where  the  thought  is  called  up  by  a  perception  the 
imperative  idea  consists  of  the  continued  activity  of  apperception  with 
reference  to  the  original  disturbing  thought  and  the  associated  fears 
and  imitative  impulses  which  occur  with  special  intensity,  even  with 
violent  fear,  when  the  original  perception  or  one  related  to  it  recurs. 
In  the  greatly  intensified  state  of  excitability  of  the  ideational  sphere 
that  exists  in  such  patients,  the  most  unrelated  memories  and  percep- 
tions may  call  up  the  imperative  idea.  Not  infrequently  this  happens 
through  contrast. 

I  have  reported  a  great  number  of  cases  of  this  kind  in  other  places 
(Yierteljalirssclirift  für  gerichtliche  Mcäiein,  January,  1870).  It  is  not  infre- 
quent for  such  patients  to  feel  an  impulse  while  in  church  during  the  sermon 
to  blaspheme  God,  or  in  praying  to  use  the  word  hell  instead  of  heaven;  at 
the  sight  of  relatives,  to  think  of  murder;  in  crossing  water,  to  think  of  push- 
ing in  a  person  present;  at  the  sight  of  weapons,  to  commit  suicide  or  to 
imitate  horrible  crimes,  etc.  In  certain  patients,  afflicted  with  the  impulse  to 
constant  questioning  about  religious  and  metaphysic  things,  and  with  the  im- 
perative thought  of  filth  or  poison,  we  find  associated  inabilitj'  to  touch  metal 
objects,  clothing,  etc.  (folic  du  doiite  avec  düire  du  toucJwr;  vide  "Special 
Pathology"). 

Cases  of  so-called  agoraphobia  (Westphal)  are  especially  interesting. 
When  persons  thus  afflicted  enter  an  open  space  or  pass  through  a  street  that 
is  devoid  of  people  they  are  immediately  overcome  by  the  imperative  idea  of 
the  impossibility  of  going  on,  and  thus  they  become  so  anxious  and  nervous 
that  they  are  actually  paralyzed ;  while,  if  they  keep  close  to  the  houses  or  are 
accompanied  by  some  one,  they  have  no  difficulty  whatever.  Jolly  very  cor- 
rectly compares  the  psychic  uncertainty  of  certain  neuropathic  individuals, 
when  required  to  act  in  the  presence  of  others,  and  impotentia  psychica 
coeundi  with  these  interesting  conditions  of  agoraphobia. 

Emminghaus  classes  these  phenomena  with  states  of  anxiety;  but  this 
anxiety  is   clearly  only  a  reactive,  if  not  a  subsidiary,  phenomenon.    The 


ELEMENTARY  ANOMALIES  OF  THE  CEURBRAL  rnxci'IOXR.       ßo 

primary  element  is  the  imperative  idea  of  impossiliility  of  action  and  the 
danger  connected  with  it.  The  imperative  thouglit  is  either  founded  in  a 
temporary  or  lasting  feeling  of  muscular  weakness  (Cordes  explains  agora- 
phobia simply  as  exhaustion-paresis),  or  in  the  memory  of  a  fright,  accident, 
or  failure  which  arose  under  similar  previous  circumstances.  In  the  latter 
case  consciousness  of  former  and  present  muscular  weakness  and  disturbance 
of  general  feeling  are  also  operative.  The  feeling  of  incapacity  or  the  thought 
of  previous  failure  then  makes  action  impossible  even  to  the  degree  of 
helplessness.  The  painful  situation  in  which  the  patient  finds  himself  leads 
to  anxiety,  as  a  result  of  which  the  painful  feeling  becomes  still  more  intense. 
This  is  followed  by  vasomotor  disturbances,  pallor,  sweating,  palpitation,  loss 
of  muscular  tone,  leading  to  shaking  of  the  knees,  trembling,  and  loss  of  the 
senses:  true  nervous  crises.  There  are  iiTunerous  analogies  of  so-called  agora- 
phobia which  occur  in  neuropathic  individuals  (comp.  Beard,  "Neurasthenia"), 
among  which  the  aversion  to  going  out  alone,  resulting  from  thought  of 
threatening  danger  (e.g.,  apoplexy)  and  impossibility  of  medical  aid;  fear  of 
riding  in  a  closed  carriage  or  of  going  among  people  because  of  actual  or 
imaginary  fear  of  blushing;  fear  of  closed  rooms  like  theaters  and  concert- 
halls,  unless  a  corner  seat  is  obtainable;  fear  of  thunder  and  lightning,  etc., 
are  the  most  frequent. 

Under  all  circumstances  where  such  imperative  thoughts  and  fears  occur 
there  is  a  state  of  irritable  weakness  in  the  central  nervous  system  as  one 
symptoili  of  a  temporary  or  lasting  functional  weakness  of  the  brain  (neu- 
rasthenia). This  is  also  true  of  those  well-known  physiologic  imperative 
thoughts  and  impulses,  such  as  the  inclination  to  throw  one's  self  off  of  towers 
and  high  places  or  to  push  others  off.  They  always  occur  when  there  is  a 
relative  exhaustion  resulting  from  mental  strain,  sleeplessness,  lack  of  food, 
etc.,  and  they  disappear  after  eating  and  after  indulging  in  alcohol;  just  as 
those  who  are  afflicted  with  agoraphobia  and  similar  conditions  are  temporarily 
relieved  by  the  same  means.^ 

Imperative  ideas  of  ner%'ous  and  mental  patients  likewise  are  always 
founded  upon  a  state  of  neurasthenia.  Frequently  these  individuals  are  con- 
stitutionally neuropathic,  though  numerous  cases  occur  in  which  neurasthenia 
is  acquired.  Sexual  excesses,  onanism  in  particular,  are  especially  influential 
as  causes;  and  besides,  mental  strain,  especially  when  associated  with  emo- 
tional excitement,  exhausting  diseases,  the  puerperal  state,  etc.  In  his 
experience  Cordes  found  prolonged  gastric  disturbances  and  corpulency  with 
fatty  heart  to  be  causal  factors. 

The  first  occurrence  of  an  imperative  idea  during  a  phase  of  special  ex- 
citement (menses,  pregnancy,  lactation),  or  with  some  simultaneous  weaken- 
ing excess,  and  the  success  of  tonic  treatment,  are  other  important  indices. 

Imperative  ideas  are  elementary  disturbances  which  occur  in  the  course 
of  mental  disease  (melancholia,  paranoia),  or  in  a  neurosis  (neurasthenia, 
hysteria,  hypochondria) ;    or  they  are  primary,  multiple,  and  lasting,  and  lead 


"^  Agoraphobia,  claustrophobia,  and  fear  on  high  places  often  have  a 
physical  foundation  in  lesion  of  the  internal  ear.  No  case  of  this  kind  should 
ever  be  allowed  to  pass  without  careful  examination  of  the  reaction  of  the 
patient  to  the  galvanic  current  in  the  test  for  voltaic  vertigo  (vide  footnote 
on  page  113). — Translator. 

s 


66  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

to  secondary  anomalies  of  feeling  and  action;  so  that  they  represent  a  true 
insanity  of  imperative  ideas  ■\vhieli  requires  special  description  in  the  section 
on  special  pathology. 

(D)  Disturbances  of  Aj) perception. 

In  order  that  a  sensor}^  impression  may  be  recogiiized,  it  is  neces- 
sary that  it  call  up  in  the  perceptive  centers  of  the  cerebral  cortex  the 
corresponding  memory-picture.  This  result  is  favored  by  a  process 
of  innervation  taking  place  in  the  psychic  organ  which  we  are  accus- 
tomed to  call  attention.  The  intensity  of  this  excitive  process  is 
constantly  varying,  and  thus  the  threshold  of  excitability  of  the 
central  organ  is  constantly  varied.  Expectation  of  a  sensory  impres- 
sion favors  its  perception,  while,  on  the  other  hand,  a  great  number 
of  sensory  impressions  never  attain  to  the  distinctness  of  perceptions, 
because  attention  is  wanting  or  diverted. 

Apperception  is  changed  in  the  insane.  It  is  lessened  or  may  be 
entirely  wanting  as  a  result  of  concentration  of  consciousness  upon 
inner  phenomena  (melancholia  with  stupor,  ecstasy);  just  as  in  the 
case  of  a  normal  person  who  is  pre-occupied  with  some  mental  work, 
so  that  only  that  wliich  lies  in  the  narrow  field  of  thought  is  perceived. 

Analogous  phenomena  occur  in  sleep-walkers,  who  perceive  only 
those  things  which  are  related  to  the  ideas  which  constitute  their 
dreams ;  likewise  in  hypnotic  somnambulism,  where  perceptions  result 
only  from  suggestion.  Apperception  may  also  be  impossible  as  a 
result  of  want  of  excitability  of  the  perceptive  organ  (states  of  exhaus- 
tion, stupor),  or  owing  to  the  destruction  of  the  latter:  i.e.,  the 
destruction  of  the  memory-pictures  once  stored  in  the  destroyed  center 
(mental  deafness,  mental  blindness,  dementia).  An  increase  in  the 
powers  of  apperception  takes  place  in  the  emotional  states  of  expecta- 
tion, both  in  the  healthy  and  diseased,  and  also  in  the  milder  degrees 
of  psychic  excitation  (maniacal  exaltation,  hysteria,  febrile  states). 
This  is  manifested  not  merely  in  increased  ease  of  apperception,  but 
also  under  some  circumstances  (many  hysterics,  hypochondriacs)  in  a 
sharpening  of  perception.  Emminghaus  justly  calls  attention  to  the 
fact  that  in  this  erethism  of  the  brain  the  attention  is  constantly 
excited  by  sensory  phenomena.  As  a  result  of  this  one-sided  control  of 
consciousness  the  intracentral  activity  of  thought,  judgment,  etc.,  must 
be  disturbed  (confusion  as  the  opposite  of  concentrr.tion). 

(E)  Disturbances  Affecting  the  Exactness  of  the  Reproduction 
of  Ideas  (Memory). 
Eeproduction  of  ideas  may  take  place  with  abnormal  ease  or  with 
abnormal  difficulty. 


ELEMENTARY  ANOMALIES  OF  THE  CE[11^:BRAL  FUNCTIONS.       67 

Eacilitated  reproduction  (hj^pcrmnesia)  as  found  in  states  of 
exaltation  (mania)  is  one  of  the  symptoms  of  the  general  increased 
ease  with  which  ps_yc]nc  processes  take  place.  It  is  invariably  accom- 
panied by  abnormally  intense  coloring  of  reproduced  images.  In  such 
states  of  exaltation  the  freshness  and  clearness  with  which  numerous 
images  and  ideas  which  apparently  had  disappeared  are  recalled  into 
consciousness  are  astounding.  More  important  and  more  frequent 
are  the  interference  and  loss  in  the  domain  of  memory  (amnesias). 
Amnesia  depends  either  upon  a  simple  and  usually  temporary  inhibi- 
tion of  reproduction  of  virtually  retained  ideas  or  is  based  upon  an 
actual  and  lasting  loss  of  mental  pictures. 

In  the  first  case  there  is  a  simple  functional  disturbance  in  the 
organ  of  memory.  Here  the  hindered  or  temporarily  impossible  repro- 
duction is  a  symptom  of  the  general  inhibition  of  psychic  processes 
(melancholia,  cerebrastbenia),  or  of  a  more  or  less  severe  exhaustion 
of  the  psychic  organ  (states  of  mental  fatigue  and  exhaustion),  and  it 
is  in  part  referable  to  faintness  of  external  impressions,  defective 
emotional  coloring  of  ideas,  and  weakened  or  inhibited  association  of 
ideas.    The  patient  is  painfully  conscious  of  this  disturbance. 

Actual  loss  of  memory-pictures  is,  as  a  rule,  a  lasting  defect  of 
mental  power  conditioned  by  grave  destructive  diseases  of  the  psychic 
organ  (dementia  paralytica,  dementia  senilis,  etc.). 

In  this  case  amnesia  in  the  true  sense  of  the  word  exists.  In  the 
beginning  of  these  destructive  processes  there  is  merely  a  weakness  of 
reproduction  of  the  latest  events.  Ribot  shows  empirically  hoAV  in 
progressive  brain  diseases  the  weakness  of  rej)roduction  progresses,  as 
it  were,  in  accordance  with  a  law,  so  that  ultimately  it  affects  the 
memory  of  earliest  events  (progressive  amnesia)  ;  that  finally  even 
the  impressions  of  childhood — indeed,  even  the  memory  of  previous 
personality — are  lost. 

In  the  infrequent  cases  in  which  memory  returns  (certain  cases  of 
stupidity  and  traumatic  insanit}^)  the  re-creation  of  memory-pictures 
takes  place  in  an  inverse  manner  compared  with  the  manner  in  which 
they  were  lost;  those  for  latest  events  are  the  last  to  be  recovered. 

The  patient  whose  memory  for  late  events  has  been  lost  lives  in 
time  long  past.     These  lost  intervals  may  cover  years  or  even  decades. 

Amnesia  may  also  occur  episodically  and  be  but  temporary,  in  that 
events  which  take  place  during  the  time  of  disease  can  be  reproduced 
only  incompletely  or  not  at  all. 

The  answer  to  the  question  whether  events  of  a  sickness  will  be 
later  reproduced  depends  upon  the  intensity  of  the  disturbance  of  con- 
sciousness occasioned  by  the  pathologic  process;  at  least  with  relation 


nS  rJF.XKIJAL  PATTTOLOGY  AND  'niKl'vAPY  OF  INSANITY. 

to  this,  there  is  a  decided  parallel  between  the  disturbanee  of  memory 
and  the  disturbance  of  consciousness.  There  is  also  a  similar  relation 
between  the  hitter  and  the  acuteness  of  the  disease-jn-oeess. 

iii  \ccv  ariHt>  states  of  insanity  iiicini)i-\  fails  ahiiust  entirely 
(lialholoiric  slates  of  alcuhnli-iii.  loxi,-  «Id  i  riuiu.  iraiisitorv  mania, 
ra|)liis  iiu'hiiicholirns.  lii-aiid  mal  of  f|iih'pl  ic-.  pat  hnlooic  alVects,  etc.). 

Ill  MMiic  i-asrs  it  is  liniilcd  to  the  i-nntcnl  of  the  dclii-ioiis  (ecstasv. 
soininimbulisiii,  ci'i-laiii  cpileptie  slates),  whicli  iiiav  lie  explained  b*' 
the  fact  that  diii'ing  the  condition  lack  of  percept idh  of  the  external 
world  exists,  or  at  least  the  sensory  impressions  take  place  but  sparingly 
or  faintly,  while  the  central  spontaneous  excitation  (as  a  result  of 
physiologic  organic  excitement)  is  very  lively. 

In  acute  insanity  (acute  melancholia,  mania,  hallucinatory  in- 
sanit}^  stupor,  and  certain  states  of  epileptic  delirium)  memory  is 
usually  only  summary. 

In  chronic  cases  memory  of  all  events  and  experiences  is  often 
retained  in  most  painful  detail. 

Especially  interesting  are  those  cases  in  whicli  anuiesia  of  the  time  of  the 
sickness  extends  over  a  certain  time  of  the  normal  life  before  the  attack. 

An  interesting  example  of  this  "destructive  temporary  amnesia"  is  re- 
ported by  Ribot.  A  young  wife  in  the  puerperal  state  Mas  taken  with  an 
attack  of  long-continned  fainting.  When  she  regained  consciousness  she  had 
lost  memory  for  all  that  had  taken  place  since  her  marriage,  while  she  still 
retained  an  exact  memory  for  all  events  of  her  life  up  to  that  period.  Her 
husband  and  child  appeared  to  her  as  strange  persons;  only  upon  the  evi- 
dences of  her  relatives  would  she  believe  that  she  was  married. 

Such  retroactive  amnesia  is  not  infrequent  after  head  injuries. 

Finally  the  partial  amnesias  are  of  great  scientific  interest.  The 
latest  physiology  of  the  cerebral  cortex — in  accordance  with  which 
there  is  a  central  area  for  each  sense,  a  place  where  memory-pictures 
are  stored  up — explains  these  cases  at  once.  Functional  and  focal 
diseases  of  the  cortex  may  cause  these  amnesias.  Examples  of  this 
are  offered  by  cases  of  aphasia,  mental  blindness,  and  mental  deafness. 

Such  partial  amnesias  are  not  infrequent  as  temporary  and  epi- 
sodic phenomena  in  the  hysteric  and  epileptic  psychoses,  and  also  in  a 
lasting  and  progressive  form  in  the  initial  stages  of  dementia  paralytica 
and  senilis.  Apparently  those  powers  of  memory  which  are  weakly 
constituted  or  which  have  been  little  used  are  the  first  to  be  lost. 

As  a  transition  to  the  elementary  disturbances  of  the  following 
section  we  have  yet  to  consider  the  disturbances  of  memory  which  con- 
sist of  this:  that  ideas  appear  in  consciousness  which  are  supposed 
to  be  memory-pictures,  or  actual  memory-pictures  reproduce  them- 
selves in  a  false  form. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       69 

This  category  of  disturbances  of  memory,  which  touches  the 
domain  of  disturbances  of  imagination,  of  consciousness  (critic),  and 
illusion,  may,  with  Kräpelin,  be  called  paramnesia,  or  fallacies  of 
memory;  or,  with  Sully,  illusions  of  memory.  In  analogy  with  er- 
rors of  the  senses,  Sully  well  differentiates: — 

(a)  Phantasms  of  memory:  i.ß.,  supposed  memory  of  things 
which  have  never  been  experienced. 

In  this  condition  pure  fancies  are  regarded  as  having  been  actually 
experienced.  These  phantasms  of  memory  are  due  to  fallacies  of  dis- 
crimination, and  depend  upon  weakness  of  judgment  or  upon  special 
intensity  of  the  present  impression  which  calls  up  the  supposed 
memory-picture.  This  confounding  of  an  actually  lively  idea  with  a 
memory-picture  is  very  common  in  paralytics,  who  tell  of  supposed 
visits  and  adventures,  relate  fabulous  tales  covering  periods  of  their 
lives,  and  even  surpass  the  famous  Miinchhausen  ("hallucinations  of 
memory,  or  pseudo-hallucinations").  Improperly,  as  a  result  of  pure 
defect  of  discrimination,  the  confusion  of  what  has  been  dreamed, 
read,  heard,  or  experienced  in  delirium  with  that  which  has  been 
actually  experienced  belongs  here.  This  paramnesia,  consisting  of 
confusion  like  that  which  occurs  in  children  who  confound  actuality 
and  the  events  of  dreams,  may  occur  in  the  initial  stage  of  dementia 
senilis,  in  states  of  neurasthenic  exhaustion,  and  in  dementia  para- 
lytica. This  fallacy  is  quite  insignificant,  since  it  is  soon  totally  for- 
gotten. 

More  frequent  and  important  are  the  analogous  phenomena  that 
occur  in  melancholies,  who  confuse  crimes  of  which  they  hear  or  read 
with  those  they  may  have  committed,  and  under  some  circumstances 
accuse  themselves  of  them;  and  also  the  confusion  of  delusional  ideas 
with  actual  events  by  paranoiacs  and  the  delusional  insane. 

Kräpelin  justly  points  out  that  these  errors  of  discrimination  (fal- 
lacies of  memory — Kräpelin)  differ  from  pure  creations  of  the  imag- 
ination in  the  constancy  of  their  content  in  contrast  with  the  chang- 
ing and  altered  content  of  the  latter  when  repeatedly  related. 

(h)  Illusions  of  memory  in  the  narrower  sense:  i.e.,  memory- 
pictures  in  fallacious  or  defective  form.  This  disturbance  depends 
upon  defective  reproduction  and  lively  fancy,  or  upon  the  falsifying 
illusional  influence  of  a  momentary  state  of  emotion.  "Here  the  past 
appears  in  the  color  of  the  present"  (Sully)  ;  the  latest  moment  pla3-s 
a  very  active  role  in  the  memory-illusions  of  the  melancholic  and  the 
maniacal. 

The  first  conditions  occur  in  states  of  mental  weakness,  in  para- 
noiacs, and  in  the  hysteric. 


70  GENERAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

The  weakness  of  exact  reproduction  peculiar  to  these  patients  is 
also  common  in  those  afflicted  with  moral  insanity.  As  a  result  of  it 
the  reproduced  image  is  merely  similar  to  the  original  idea,  not  identi- 
cal, though  thought  to  be  identical.  Such  patients  arc  necessarily 
unconsciously  untruthful,  because  that  which  has  been  experienced 
is  reproduced  by  tlieni  in  a  totally  changed  form. 

There  is  yet  to  ho  ineutioned  a  peculiar  form  of  paramnesia — the 
so-called  '"balhuiiiatiiMi  of  memory":  i.e.,  the  identification  of  a 
present  sitiiaiiDii  with  one  which  is  assumed  to  have  been  experi- 
enced. This  interesting  faUacy  more  frequently  occurs  in  the  sane, 
in  states  of  slight  fatigue  or  exhaustion,  than  in  the  insane  (paranoia, 
states  of  mental  weakness,  epilepsy,  sometimes  also  mania.  Neu- 
rasthenics are  also  not  infrequently  affected  by  this  fallacy.  With 
consciousness  intact,  a  painful  feeling  of  uncertainty  is  connected  with 
it.  Faintness  of  immediate  impressions,  as  well  as  similarity  of  them 
and  a  former  situation,  seems  to  lie  at  the  foundation  of  this  fallacy ; 
possibly  also  faintness  of  the  memory-pictures  analogous  to  that  which 
occurs  in  the  mistaking  of  persons  is  also  effectual. 

(F)  AnomaHes  of  Beprodudion  of  Ideas  in  Changed  Form 
(Imagination). 

Just  as  in  disturbances  of  memory,  there  occur  here  also  states 
of  increased,  weakened,  or  lost  imagination.  States  of  increased 
imaginative  power  occur  in  insanity  in  general  in  states  of  psychic 
excitement  and  facilitated  association  of  ideas.  The  emotional  warmtli 
of  ideas  and  their  intensity,  largel}'  increased  as  a  result  of  their  phys- 
iologic origin,  favor  the  activity  of  the  fancy.  Its  creations  then 
approach  the  borderland  of  phantasms,  and  often  such  especially  lively 
ideas,  which  the  insane  have  in  common  with  the  child  and  the  artist, 
are  mistaken  for  actual  hallucinations  {vide  "Pseudo-hallucinations"). 

The  activity  of  imagination  is  especially  intensified  in  the  excitcl 
states  of  paralytics,  in  certain  epileptics,  and  in  paranoia,  especially 
in  the  original  form  of  this  disease. 

The  legendary  and  plastic  stories  of  such  patients  leave  nothing 
to  be  desired  as  far  as  the  warmth  of  fancy  is  concerned,  even  though 
they  may  be  wanting  in  esthetic  worth  and  logical  connection;  they 
sometimes  surpass  even  the  finest  fancy  of  the  poet. 

'  The  loss  of  imagination  and  the  preceding  strange  and  monstrous 
character  of  the  creations  are  signs  of  mental  weakness,  and  in  insane 
artists  they  are  a  delicate  index  of  the  initial  stage  of  psychic  decay 
(loss  of  esthetic  feeling). 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       71 

2.  Fallacies  in  the  Content  of  Ideas  (Delusions). 

Delusions — i.e.,  anomalies  in  the  content  of  ideas  as  a  result  of 
brain  disease — are  among  the  most  interesting  and  important  insane 
phenomena. 

The  idea  of  the  laity  that  the  decisive  marks  of  insanity  are  delu- 
sions is,  however,  erroneous.  Instead  of  those,  merely  formal  dis- 
turbances of  the  processes  of  thought,  or  phenomena  indicating  loss 
on  the  intellectual  side  of  mental  life,  may  be  the  jirominent  symp- 
toms in  the  disease-pictures. 

The  proof  of  the  existence  of  a  delusion  as  a  symptüm  of  mcjital 
disease  is  of  the  greatest  importance. 

It  does  not  follow  because  some  one  has  expressed  a  delusional  idea 
that  he  is  insane.  The  sane  may  entertain  the  most  outlandish  false  ideas, 
and  even  in  this  respect  surpass  the  insane.  On  the  contrary,  tVie  delusion  of 
an  insane  person  need  not  necessarily  contain  an  objective  impossibility  (de- 
lusion of  marital  infidelity,  of  poisoning,  etc.)  ;  indeed,  the  delusion  itself  may 
he  objectively  correct  and  at  the  same  time  have  the  value  of  a  delusion:  like 
the  idea  of  a  hypochondriac  melancholic  (possibly  luetic)  that  he  is  infected, 
the  idea  not  resting  on  a  diagnosis  based  upon  a  knowledge  of  medicine,  but 
upon  his  effort  to  explain  general  disturbances  of  feeling  and  consciousness, 
which  might  quite  as  well  be  attributed  to  some  other  disease  with  which  he 
is  not  afflicted,  in  order  to  explain  his  abnormal  sensations.  In  the  psychiatric 
sense  the  content  of  a  delusion  is  not  decisive  for  the  determination  of  the 
existence  of  insanity;  the  less,  since  even  the  most  monstrous  content  does 
not  prove  that  the  individual  is  convinced  of  the  truth  of  the  idea;  for  simu- 
lation may  be  in  play.  Even  the  circumstance  that  a  man  acts  in  accordance 
with  the  delusion  which  he  expresses  can  be  no  criterion. 

Here  it  is  not  the  content  which  is  decisive,  but  the  manner  of 
origin  of  the  delusion  in  question  with  its  interpretation  and  relation 
to  the  past  and  present  consciousness. 

For  the  differentiation  of  the  delusion  of  an  insane  person  from  the 
errors  of  the  sane,  the  following  points  are  of  value: — 

1.  The  delusion  is  a  product  of  a  brain  disease,  and  thus  has  a  patho- 
genesis ;  it  is  further  a  symptom  of  a  general  abnormal  condition,  and  thus  is 
genetically  and  clinically  related  to  other  symptoms,  affects,  abnormal  emo- 
tions, sensations,  etc. 

On  the  other  hand,  the  error  of  a  sane  person  depends  upon  a  defect  of 
logical  judgment  or  upon  a  false  premise  that  has  arisen  out  of  uncertainty, 
carelessness,  or  embarrassment  in  the  act  of  perception  (affects,  superstition, 
etc.). 

2.  A  delusion  of  the  insane  is  a  symptom  of  a  brain  disease,  and  there- 
fore logic  and  reasoning  are  powerless  against  it.  It  stands  and  falls  with 
the  causal  disease.  It  is  quite  as  easy  to  argue  the  delusion  out  of  a  patient 
as  it  is  to  cure  him  of  his  disease  by  talking.     On  the  other  hand,  the  sane 


72     GENERAL  PATHOLOGY  AND  THERAPY  OF  INSAIMTY. 

person  will  see  his  error,  and  correct  it  as  soon  aa  it  is  shown  to  him  to  be 
absurd. 

3.  Since  the  delusion  of  a  patient  depends  upon  a  grave  disturbance  of 
mental  functions,  it  is  clear  that  it  must  stand  in  striking  contrast  with  his 
fonner  ego,  with  his  previous  manner  of  thinking  and  experience  (think  of  a 
pliysicist  who  fancies  he  can  fly;  of  a  mathematician  who  thinks  he  has 
squared  the  circle;  of  a  chemist  who  thinks  he  has  discovered  the  art  of  mak- 
ing gold).  The  error  of  a  sane  person  will  be  understood  when  it  is  considered 
with  relation  to  his  previous  opinions  and  his  previous  education;  at  least,  it 
AA'ill  not  stand  in  contradiction  with  these. 

4.  The  delusion  of  an  insane  patient  always  has  a  subjective  significance 
and  an  inner  relation  to  his  interests;  that  of  a  sane  person  appears  only  as 
an  objective  error.  Thus,  both  may  believe  in  witches;  the  sane  person,  how- 
ever, as  a  result  of  superstition  and  ignorance;  the  insane  person  believes  in 
them  because  he  sees,  feels,  and  believes  himself  threatened  by  them. 

This  explains  the  varying  manner  in  which  they  both  react  to  their  delu- 
sions: that  of  the  sane  person  remains  without  special  inÜuence  upon  his 
acts;  that  of  the  insane  patient — until  psychic  weakness  intervenes — may 
induce  the  most  violent  emotional  reaction  and  acts.  Here  it  is,  indeed,  "tua 
res  agititr." 

Decisive  diagnostic  weight  can  be  laid  upon  a  delusion  only  when 
it  has  been  followed  back  to  the  conditions  of  its  origin. 

How  do  delusions  originate?  Ways  in  which  they  originate  are 
exactly  like  those  in  which,  in  physiologic  life,  the  content  of  experi- 
ence is  enlarged.  We  gain  correct  opinions  first  from  judgment 
based  upon  given  premises,  in  case  both  conditions  are  perfectly  ful- 
filled (ideational  or  combinational  way)  ;  or,  secondly,  as  a  result  of 
now  correct  sense-perceptions  (apperceptive  way).  In  accordance 
with  this,  then,  delusions  arise,  first,  as  a  result  of  false  judgments 
(ideational  way)  ;  or,  secondly,  as  a  result  of  false  perceptions  (hallu- 
cinatory way). 

In  accordance  as  they  arise  either  by  ideation  or  hallucination, 
delusions  may  be  divided  into  intellectual  and  sensorial  delusions. 
The  idea  which  becomes  a  delusion  or  hallucination  may  arise  cither 
in  the  conscious  or  unconscioifs  mental  sphere.  In  the  first  case  the 
transformation  to  a  delusion  depends  upon  a  conscious  psychologic  act ; 
in  the  second  case  we  must  assume  the  existence  of  an  organic  uncon- 
scious origin,  out  of  which  the  delusion  appears  in  consciousness  as  a 
completed  result. 

The  ways  in  which  disturbances  of  the  content  of  ideas  may  arise 
within  the  sphere  of  consciousness  are  the  following : — 

(a)  False  judgment  concerning  abnormal  states  of  consciousness 
(emotional  states,  affects,  etc.)  or  sensations. 

(h)  False  combination  of  percepts  and  experiences  in  general  to 
form  defective  conclusions. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       73 

(c)  The  confusion  of  what  has  been  dreamed,  road,  etc.,  with 
actual  events. 

Possibilities  under  a  and  h  may  be  called  delusions  of  judgment; 
those  under  group  c,  delusions  of  memory. 

Delusions  that  arise  unconsciously  or  organically  may  be  due  to 
central  or  reflex  processes. 

In  the  first  case,  the  delusion  appears  as  the  direct  product  of  dis- 
turbance of  nutrition  in  the  cerebral  cortex  (febrile,  toxic,  inanition). 
In  the  second  case,  the  delusion  arises  indirectly  and  reflexly,  and 
is  induced  by  the  transference  of  a  state  of  excitation  from  a 
peripheral  organ.  In  this  relation  functional  and  organic  dis- 
turbances of  the  digestive  (hypochondriac  delusions)  and  genital 
(erotic  delusions)  organs  are  especially  important.  Of  great  clinical 
importance  is  the  contrast  which  exists  between  false  ideas  arising 
from  erroneous  ideational  and  associative  activity  with  consequent 
effort  to  explain  them  in  the  sphere  of  consciousness,  and  those  whicli 
depend  upon  an  organic  foundation  and  enter  consciousness  in  a  com- 
pleted form.  Owing  to  this  distinction,  it  would  be  well  to  use  dis- 
tinctive terms  and  call  the  first  delusions  and  the  second  deliria. 

The  former  also  differ  from  the  latter  in  that  their  psychologic 
mode  of  origin  is  clear ;  they  may  be  referred  to  their  genetic  cause ; 
they  are  in  accord  with  the  predominating  emotional  state ;  they  enter 
into  the  process  of  association  of  ideas,  become  logical  elements  of 
thought,  and  lead  to  a  systematic  association  of  the  delusions. 

The  latter  (deliria)  are,  on  the  contrary,  out  of  harmony  with 
the  present  feelings  and  ideas,  and  possibly  in  contradiction  with  them. 
They  do  not  logically  satisfy  the  patient,  but  surprise  and  astound 
him;  they  have  rather  a  painful  than  a  quieting  effect,  like  that  of 
imperative  ideas.  At  first  the  patient  does  not  know  how  to  compre- 
hend these  ideas ;  only  later  and  with  great  difficulty  does  he  assimilate 
them  and  find  a  motive  for  them,  after  they  have  come  to  exert  an 
influence  upon  his  thought  and  feelings.  At  first  they  act  as  an  annoy- 
ance, not  as  a  relief. 

A  further  interesting  question  is :  "What  influences  have  an  effect 
upon  the  content  of  delusions  and  deliria  ? 

The  opinion  of  the  laity  that  the  content  of  a  delusion  depends  upon 
special  moral  causes  that  may  have  caused  the  outbreak  of  insanity  is  erro- 
neous; for  it  is  only  in  rare  cases  that  events  which  were  disturbing  and 
occurred  before  or  caused  the  outbreak  of  disease  are  carried  over  into  and 
expressed  in  the  insane  state ;  in  certain  cases  their  effect  may  not  have  disap- 
peared, or  it  may  be  repeatedly  reproduced  by  some  physical  anomaly,  such  as 
a  neuralgia,  that  has  resulted  from  shock  and  is  genetically  associated  with  the 
fundamental  idea.     As  a  rule,  they  do  not  appear  in  the  content  of  abnonnal 


74  GEXERAL  rATHOLOGY  AND  TIIERAPY  OF  INSANITY. 

consciousness,  since  they  are  only  a  link  in  the  chain  of  etiologic  elements,  or 
pathogenicnlly  irrelevant.  The  decisive  factor  is  the  brain  disease.  This,  as 
a  rule,  biings  about  a  change  of  consciousness  and  an  altered  content  of  con- 
sciousness, and  by  its  peculiar  character  determines  the  content  of  eventual 
delusions. 

The  peculiar  content  of  delusions  (deliria)  seems  to  depend: — 

1.  Upon  the  nature  of  the  abnormal  processes  in  the  cerebral 
cortex.  It  is  surprising,  and  it  was  justly  pointed  out  by  Griesinger, 
liow  in  certain  abnormal  states  patients  of  different  races  and  epochs 
present  the  same  typical  delusion,  just  as  if  the  patients  had  read  tlio 
same  novel  or  had  been  infected  one  by  another.  This  remark  is  espe- 
cially true  with  regard  to  delusions  of  primary  origin,  devoid  of  hallu- 
cinatory or  emotional  foundation,  like  those  that  occur  in  paranoia 
(delusions  of  persecution  and  grandeur),  in  dementia  paralytica 
(primary  delusions  of  grandeur),  in  dementia  senilis  (nihilistic  delu- 
sions), and  in  chronic  alcoholism  (delusions  of  jealous}-).  Certainly 
in  these  cases  the  similarity  of  the  disease-process  must  be  the  founda- 
tion for  the  similar  content  of  the  delusions. 

Griesinger  proposed  the  name  of  primordial  deliria  for  these  primary 
and  congruent  false  ideas,  and  he  ingeniously  compared  them  with  the  color 
deliria  that  occur  in  epileptics  as  an  aura  of  attacks,  where  the  central  excita- 
tion induces  auras  of  only  a  few  colors  (especially  red)  in  all  patients,  though 
the  possibility  of  a  variety  of  colors  is  so  gi'eat. 

Likewise  the  typic  delusions  in  delirium  tremens,  in  opium  intoxication, 
and  in  some  other  toxic  states  are  caused  by  specific  stimuli. 

Considering  these  facts,  it  seems  a  just  question  whether  there  are 
typical  deliria  of  diagnostic  value  in  the  psychoses.  This  question  requires 
careful  investigation.  In  the  present  state  of  our  knowledge  we  may  say  that 
there  are  deliria  and  combinations  of  deliria  which  possess  an  empiric  diag- 
nostic value  in  themselves,  and  which  to  the  expert  constitute  a  direct  indica- 
tion of  a  special  form  of  disease,  or  at  least  of  a  special  cerebral  condition. 

Thus  there  are  micromaniaeal  and  nihilistic  delusions  which  justify  the 
suspicion  of  a  severe  organic  psychosis  (dementia  paralytica  and  dementia 
senilis)  or,  at  least,  the  assumption  of  a  psychosis  affecting  a  degenerate  brain. 

Not  less  noteworthy  are  the  romantic  typic  delusions  of  persecution  and 
grandeur  that  occur  in  the  original  (Sander's)  form  of  paranoia;  the  delusion 
of  physical  persecution  in  late  paranoia  developed  upon  a  neurasthenic  basis, 
with  a  special  indication  in  a  case  that  has  arisen  out  of  neurasthenia  sexualis, 
when  the  delusions  are  accompanied  by  olfactory  hallucinations;  the  auditory 
hallucination  of  obscene  persecutory  content  in  alcoholic  delusional  insanity; 
the  expansive  religious  persecutory  delusions  in  many  epileptics  with  "deistic 
nomenclature  and  royal  delusions"  (Samt)  ;  and  the  typic  imperative  ideas  of 
the  "maladie  du  doute  avec  d6Ure  du  toucher." 

2.  The  special  content  of  false  ideas  is  dependent  upon  the  pre- 
dorainatinof  state  of  feulinu;  and  direction  of  thought.     This  is  true 


ELEMENTARY  ANOMALIE?  OF  THE  CEREBRAL  FUNCTIONS.       75 

of  all  delusions  resulting  from  false  judgment  (false  attemjits  at  ex- 
planation of  abnormal  states  of  consciousness;  interprelation  of 
sensations  in  an  abnormal  state  of  consciousness). 

3.  The  degree  of  education  and  the  life  and  occupation  of  tlie 
patients  are  largely  determinate. 

This  is  owing  to  the  fact  that  the  ahnoiiiial  thought  is  created  out  of  the 
previous  content  of  the  mind,  in  Avhich  tlic  fantastically  altered  activity  of 
imagination  exeici.ses  infinite  influence. 

This  dependence  upon  previou.s  mental  endowment  is  especially  clear  in 
the  delusions  of  paralytics.  The  political  and  social  opinions  of  various  peoples 
and  periods  are  also  mirrored  in  the  delusions  of  patients. 

The  delusions  of  persecution  by  the  devil — widespread  in  the  Middle  Ages 
— is  to-day  in  large  part  replaced  by  delusions  of  persecution  by  the  police, 
Free  Masons,  Jesuits,  etc. 

■i.  Finally,  functional  disturbances  in  extraeeplialic  organs  are 
important  either  as  causes  or  as  mere  accompaniments  of  a  psychosis. 

These  disturbances  may  induce  delusions  or  deliria  in  two  ways : — 

(a)  By  direct  organic  excitation  of  the  psychic  organ  which  does 
not  enter  consciousness,  appearing  then  in  the  form  of  primordial 
deliria  (erotic,  hypochondriac  deliria). 

(bj  As  a  result  of  false  and  frecjuently  allegoric  fantastic  inter- 
pretation of  sensations  conditioned  by  these  extracephalic  diseases, 
which  enter  consciousness,  where  the  misinterpretation  is  brought 
about  through  reflection  or  attempts  at  explanation. 

This  manner  of  origin  is  of  \he  greatest  practical  importance  and 
suggests  the  question  of  what  clinical  value  the  special  content  of 
delusions  and  deliria  has.  On  this  point  the  positions  of  the  laity  and 
science  are  fundamentally  different. 

The  laity  lays  much  stress  upon  the  peculiar  content  of  a  delusion, 
while  scientifically  it  may  be  a  matter  of  little  importance  whether  a 
patient  thinks  himself  Julius  Csesar,  Napoleon,  Bismarck,  the  Messiah, 
or  God. 

Under  all  circumstances  the  delusion  of  a  patient  is  clinically 
important  :— 

1.  Since  there  must  be  a  deep  clouding  of  consciousness,  of  judg- 
ment, and  of  discrimination  in  order  to  permit  it  to  exist;  there- 
fore a  delusion  indicates  the  existence  of  such  a  condition. 

2.  Because  it  indicates  severity  of  the  disease-process  (nihilistic, 
micromaniac  delusions  of  a  degenerate  brain),  and  it  may  even  give  a 
particular  pathologic  indication  of  some  special  form  of  disease. 

3.  The  content  of  a  delusion  may  give  etiologic,  diagnostic,  and 
therapeutic  indications  in  extracephalic  organs,  either  functional  or 


76  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

organic  in  nature,  whether  the  delu&iou  be  primordial  or  appear  as 
the  transformation  in  consciousness  of  sensations. 

It  is  the  task  of  clinical  investigation  to  extract  this  kernel  from  its  cov- 
ering of  allegory.  The  delusions  of  the  insane  are  qnite  as  far  from  being 
meaningless  creations  of  the  brain  as  the  dream-pictnres  of  the  sleeper. 

As  in  the  latter,  the  fantastic  idea  of  being  suH'ocated  may  be  dne  to  a 
beginning  angina,  the  idea  of  a  thrust  of  a  dagger  to  a  pleurisy  or  pleuro- 
dynia; so  among  the  insane,  we  frequently  find,  as  the  kernel  of  a  delusion, 
abnormal  somatic  processes  which,  of  course,  have  been  allegorically  trans- 
formed  and  fantastically  exaggerated.  Thus,  the  delusion  that  a  part  of  the 
body  has  been  lost  may  depend  upon  anesthesia  of  that  part;  the  delusion  of 
being  tortured  by  an  invisible  person,  upon  paralgic  sensations;  of  having 
snakes  in  the  stomach,  upon  increased  peristalsis  of  the  intestines;  of  an 
animal  in  the  stomach,  upon  gastric  ulcer;  of  labor  pains,  upon  uterine  colic. 
Such  demsions  of  judgment  (vide  "Illusions")  are  quite  the  rule  in  those  dis- 
ease-states which  are  developed  upon  neurasthenic,  hypochondriac,  and  hysteric 
foundations. 

4.  A  dchision  ma}^  likewise  be  important  as  a  sign  of  danger  for 
the  patient  and  those  about  him:  as  the  expression  of  an  affect 
which  controls  the  patient,  and  as  the  motive  of  feelings,  affects, 
impulses,  and  acts  which  otherwise  could  not  be  understood. 

5.  Finally  the  special  elaboration  of  the  delusion  is  a  measure  of 
the  natural  mental  power  of  the  patient. 

The  following  may  be  mentioned  as  noteworthy  kinds  of  deliria  classified 
according  to  their  content: — 

1.  Depressive  delusions. 

(aj  ^^■here  the  motive  of  delusional  change  of  relations  is  attributed  to 
personal  guilt — as  delusion  of  self-deprociation  which  occurs  in  states  of  mel- 
ancholia (delusions  of  sin  and  crime,  demonomania,  zoanthropia,  nihilistic  delu- 
sions, and  delirium  of  negation). 

(b)  ^Vith  motive  of  the  delusional  change  resting  in  others,  or  at  least 
not  in  self — delusions  of  persecution  as  they  occur  in  paranoia  and  delusional 
insanity. 

(c)  Hypochondriac   (and  micromaniacal)  delusions. 

2.  Expansive  delusions  (delusions  of  grandeur)  having  the  motive  in  at- 
tempts at  explanation  of  expansive  states  of  feeling  (mania),  or  as  primordial 
delusions  (grave  organic  diseases  of  the  brain,  especially  dementia  paralytica, 
and  also  states  of  hallucinatory  insanity  and  paranoia). 

3.  Delirium  of  apperception  arising  from  disturbances  of  reproduction 
and  apperception. 

Among  these  ai-e  delirium  metabolicum  (Mendel), — i.e.,  the  delusion  of 
being  another,  owing  to  incorrectness  in  the  reproduction  of  memory-pictures, 
changed  coloring  of  perceptions,  and  illusions;  and  also  delirium  palingnos- 
ticum  (Mendel),  depending  upon  errors  of  memory  with  defective  power  of 
discrimination.  This  delirium  of  apperception  occurs  in  paranoia,  general 
paralysis,  mclaiulinlia,  and  mania. 


ELEMENTARY  ANOMALIES  OF  TTIE  CEREBRAL  FUNCTIONS.       77 

The  influence  of  delusions  upon  the  mental  life  in  general  is 
powerful  and  important;  the  reaction  to  tlie  delusion  is  almost  the 
same  as  if  the  delusion  were  an  actun]  ity  in  normal  mental  life.  There- 
fore knowledge  of  the  previous  personality,  the  temperament  and 
character  of  the  patient,  is  of  special  value  in  answering  the  prac- 
tically important  question  as  to  whether  and  how  a  patient  will  react 
to  his  delusion.  This  is  very  clearly  shown  in  paranoia  with  delusions 
of  persecution. 

In  general,  acts  arising  from  delusions  may  be  expected  from  a 
patient  as  long  as  the  delusion  is  fresh  and  continually  excited  by 
emotional  states  and  hallucinations.  Abnormal  emotions  and  aifects, 
especially  that  of  fear,  may  be  very  powerful.  Proof  that  these  reac- 
tive phenomena  are  the  result  of  the  delusion,  and  not  primary,  and 
therefore  anomalies  which  condition  the  formation  of  the  delusion, 
are  of  the  greatest  differential  diagnostic  importance. 

An  important  clinical  difference  depends  upon  whether  the  delu- 
sion is  fixed  or  transient.  In  the  first  case,  there  is  danger  of  a  dis- 
turbance of  series  of  ideas  that  are  still  normal,  or  at  least  danger  of 
their  distortion.  Since  the  false  idea  has  psychologically  the  same 
functional  value  as  a  correct  one,  it  is  plain  that  it  enters  into  asso- 
ciations, unites  with  feelings  and  impulses,  and  will  therefore  influence 
the  previous  personality  in  its  subsequent  feeling,  thought,  and  will. 
This  influence  may  go  so  far  as  to  bring  about  a  complete  distortion, 
even  transformation,  of  the  previous  personality. 

The  fearful  psychologic  power  of  delusions  is  no  better  illustrated 
than  by  the  fact  that  it  has  the  power  to  alter  the  most  fixed  associated 
and  historically  consolidated  mass  of  ideas  of  personal  consciousness. 
The  delusion  that  arises  in  explanatory  efforts  and  by  combination  is 
fixed.  The  delusions  that  are  provoked  by  hallucinations  may  become 
fixed  if  the  hallucinations  become  fixed. 

The  explanatory  delusion  can  always  be  referred  to  its  conditions 
of  origin  (changed  states  of  consciousness,  abnormal  sensations).  It 
also,  in  general,  corresponds  with  the  state  of  feeling  and  the  content 
of  ideas  in  general.  It  is  logically  satisfying,  and  thus  psychologically 
it  gives  relief,  and  is  thus  in  contrast  with  primordial  delusions.  The 
transitory  (desultory)  delusion  stands  in  contrast  with  the  fixed  false 
idea  and  is,  for  the  most  part,  created  by  explanatory  efforts. 

A  transitory  delusion  is  not  necessarily  congruent  with  the  state 
of  feeling,  and  it  may  be,  with  relation  to  other  ideas,  entirely  foreign. 
As  a  result  of  continual  recurrence  (many  cases  of  primordial  de- 
lirium), in  time  it  may  attain  the  significance  of  a  fixed  delusion:  i.e., 
become  assimilated  and  systematized.     But  even  a  fixed  delusion  is  not 


78  GEXEKAL  PATHOLOGY  ANJ)  THERAPY  OF  INSANITY. 

constantly  in  the  conscioiisness  of  the  patient,  no  more  than  a  correct 
idea  is  constantly  present  in  the  consciousness  of  a  healthy  person.  It 
may  become  temporarily  latent,  and  during  periods  of  remission  or 
intermission  it  may  even  be  corrected.  Such  a  condition  is  not  to  be 
confounded '  with  intentional  concealment  of  a  delusion  (dissimu- 
lation). 

Dissimulation  is  only  possible  when  there  is  a  certain  clearness 
of  consciousness  which  enables  the  patient  to  recognize  the  remarkable 
and  inopportune  character  of  his  delusion.  It  never  occurs  save  in 
cases  of  systematized  delusions,  and  actually  in  melancholia  and 
paranoia. 

It  is  a  very  erroneous  notion  that  anyone  can  be  mentally  sound 
save  with  relation  to  a  single  fixed  idea.  This  notion  is  based  upon 
confusion  of  delusion  in  the  sense  mentioned  with  tics  and  eccentrici- 
ties that  occur  within  ph3'siologic  limits  (fixed  ideas  as  understood  by 
the  laity),  or  in  connection  with  imperative  ideas. 

Partial  insanity  and  partial  responsibility  are  dangerous  theories, 
based  upon  these  assumptions. 

As  has  been  clearly  shown  by  what  has  goue  before,  a  delusion  is 
always  a  grave  disturbance  of  the  mind,  and  it  cannot  be  conceived  as 
possible  without  a  grave  disturbance  of  consciousness,  or  of  clearness 
and  power  of  judgment.  If  a  man  were  actually  sound  save  for  a  sin- 
gle delusion,  he  would  necessarily  immediately  recognize  and  correct 
the  delusion.  The  continued  existence  of  a  delusion,  in  spite  of  seem- 
ing health,  only  proves  that  the  latter  is  a])pirent,  and  the  person  is 
much  sicker  than  he  is  supposed  to  he.  TlKTcforc  it  is  (piite  nnini]iov- 
tant  so  far  as  the  general  judgment  of  the  mental  condition  of  a  patient 
is  concerned,  whether  there  be  one  or  several  fixed  ideas.  For  the  basis 
of  an  opinion  of  the  mental  condition,  one  false  idea  alone  suffices. 
The  most  remarkable  thing  for  the  laity,  however,  is  that  with  fixed  de- 
lusions there  is  logic  and  method  ;  that  the  patients  understand  how  to 
defend  ingeniously  their  delusion  against  arguments,  di-a»v  logical 
conclusions  from  their  false  premises,  and  create  a  systematized 
delusional  series  of  ideas.  This  retention  of  a  logical  form  of  thought, 
this  psychic  co-ordination  of  the  mechanism  of  thought,  presents 
nothing  remarkable,  liowever,  when  it  is  renieiuhered  that  practice  and 
habit  have  brought  these  into  a  certain  logical  formula  of  thought. 
This  capability  is  lost  only  in  terminal  states  of  mental  weakness,  and 
then  indicates  a  high  degree  of  destruction  of  the  psychic  organ. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBJIAL  FUNCTIONS.       79 

CHAPTER  IV. 
Disturbances  of  the  Motor  Side  of  Mental  Life   (Impulse  and   Will). 

1.  Disturbances  of  ti-ie  Instincts. 

Physiologic  life  presents  two  iuritinct.s :  that  of  self-preservation 
and  that  of  sexuality.  Abnormal  life  creates  no  new  instincts,  as  was 
formerly  erroneously  supposed  (the  so-called  instincts  to  murder, 
steal,  and  burn),  but  the  natural  instincts  may  be  lessened,  increased, 
or  manifested  with  perversion. 

(Ä)  Anomalies  of  the  Appetites. 

As  far  as  we  yet  know,  the  vagus,  and  not  the  sympathetic  (celiac 
plexus),  convej-s  the  common  feeling  of  hunger  to  the  sensorium.  That  the 
sense  of  hunger  is  localized  in  the  area  of  distribution  of  the  vagus  nerves  in 
the  walls  of  the  stomach  is  proved  by  the  fact  that  things  which  are  not 
assimilable  may  relieve  hunger.  Whether  the  vagus  nucleus  or  the  cortex 
gives  rise  to  the  sensation  is  uncertain  (the  cortex  in  Ferrier's  sense,  who 
places  a  center  for  genei'al  feeling  in  the  occipital  lobe;  and  in  that  of  Voit, 
who  thinks  that  it  is  probable  that  there  is  a  cortical  center  for  thirst). 

(a)  Increase  of  the  appetite  (hyperorexia)  is  not  infrequently 
episodic  or  continuous  in  the  hysteric,  neurasthenic,  and  hypochon- 
driac, since  such  persons  very  soon  after  a  meal  again  experience 
intense  feeling  of  hunger  accompanied  by  lively  general  feelings  of  dis- 
comfort which  loudly  demand  satisfaction,  but  which  are  readily  satis- 
fied by  small  quantities  of  food  (abnormal  hunger,  bulimia).  Stiller 
attributes  this  phenomenon  to  hyperesthesia  of  the  nerves  of  hunger; 
Eosenthal  attributes  it  to  hyperesthesia  of  the  gastric  centers  of  the 
vagus.  The  want  of  feeling  of  satiety  (polyphagia),  as  it  occurs  in 
chronic  dements  and  dementia,  is  usually  episodic,  and  is  to  be  dif- 
ferentiated from  this  phenomenon.  A  feeling  of  hunger  or  a  frequent 
desire  for  food  does  not  preclude  this  phenomenon.  The  patient  when 
he  sits  down  to  eat  simply  cannot  get  enough.  In  explanation  of  this, 
Eosenthal  assumes  anesthesia  of  the  vagus  centers.  Sometimes  this 
polyphagia  may  also  be  due  to  anesthesia  of  the  peripheral  endings  of 
the  gastric  nerves,  as  a  result  of  chronic  gastric  catarrh  or  dilatation  of 
the  stomach. 

An  increased  demand  for  food  may  also  be  merely  the  expression  of  ennui 
in  the  melancholic,  or  of  maniacal  desire ;  or  it  may  be  due  to  delusions.  For 
example,  a  patient  may  have  the  delusion  that  there  are  several  children  or  a 
tapeworm  in  his  abdomen,  or  that  he  is  two  persons. 

The  great  desire  for  food  which  occurs  in  the  convalescent  from  severe 
psychoses,  especially  mania,  is  a  physiologic  symptom  like  that  which  occurs 
in  convalescence  from  other  severe  diseases,  and  it  is  to  be  explained  by  re- 


80  OENEEAT,  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

iiu'iuln'iiiiy  tlic  piionnoiis  eon  sumption  of  tissues  during  the  disease,  whicli 
must  be  repUued. 

A  special  symptom  which  belongs  here  is  the  increased  desire  manifested 
by  some  patients  for  such  things  as  alcohol  and  tobacco  in  the  form  of  smok- 
ing and  snulT.  This  is  mainly  to  be  observed  in  states  of  excitement,  espe- 
cially mania."  Feelings  of  exhaustion  and  increased  pleasurable  feelings, 
associated  with  the  consumption  of  such  stimulants,  seem  to  be  the  cause. 
The  impulse  to  alcoholic  excesses  is  very  fretiuently  observed  in  states  of 
maniacal  excitement  of  a  paralytic  and  senile  nature,  and  also  in  periodic 
manias. 

In  states  of  physical  exliaustion  and  in  psychic  depre.ssion,  relief  and  re- 
freshment are  not  infrequently  sought  in  indulgence  in  alcohol,  whicli  removes 
care.  Upon  such  an  organic  basis  chronic  alcoholism  may  be  developed.  This 
is  not  infrequently  the  case  during  the  climacteric.  Persons  of  neuropathic 
constitution,  in  order  to  overcome  their  irritable  weakness,  not  infrequently 
take  to  drink  or  to  the  abuse  of  morphine. 

(b)  Lessening  of  the  appetite  (anorexia)  in  many  melancholies, 
hypochondriacs,  and  h5-sterics  depends  upon  hypesthesia  of  the  gas- 
tric nerves,  as  a  result  of  which,  after  taking  but  a  small  amount  of 
nourishment,  an  unpleasant  feeling  of  satiety  or  fullness  of  the 
stomach  is  induced, 

V  In  the  psychoses  it  is  more  frequently  not  so  much  a  diminution 
of  appetite  as  refusal  of  food  (sitophobia),  as  a  result  of  delusions; 
for  example,  of  sin,  of  no  longer  being  worthy  to  eat,  of  being  un- 
able to  pay  for  food,  of  not  having  a  body  or  of  suffering  closure  of 
the  stomach  or  intestines,  of  being  dead  or  having  dead  intestines; 
or  it  depends  upon  voices  which  command  fasting,  or  upon  hallucina- 
tions of  taste  which  make  the  food  seem  to  be  poisoned  or  unclean. 

(c)  Perversions  of  the  appetite  are  of  the  greatest  interest.  They 
occur  also  in  the  neuroses.  In  this  category  belong  the  pica  of  the 
chlorotic  (eating  of  chalk,  salt,  sand,  etc.)  ;  the  preference  of  the 
hysteric  for  things  which  have  an  unpleasant  smell  and  taste  (asa- 
1'otida,  valerian,  etc.)  ;  and  appetites  of  jiregnant  women,  who  present 
the  strangest  perversions  of  taste  (tobacco,  earth,  straw,  etc.). 

Similarly,  we  sometimes  find  in  insane  hypochondriacs,  especially  in  those 
that  are  based  upon  an  onanistic  degenerate  foundation,  an  actual  delight  in 
eating  disgusting  things:  a  true  impulse  to  eat  spiders,  toads,  worms,  human 
blood,  etc.  The  cause  of  this  may  sometimes  lie  in  the  fact  that  such  patients 
think  that  there  is  curative  power  in  these  disgusting  things.  Upon  the  same 
basis  also  rests,  perhaps,  the  desire  of  superstitious  persons  for  the  blood  of 
those  that  have  been  executed,  of  innocent  children,  virgins,  etc.,  to  which 
folklore  attributes  healing  power;   for  example,  in  epilepsy  and  lues. 

A  very  disgusting  sjTiiptom  in  the  insane  is  the  impulse  to  eat  things 
that  are  absolutely  repugnant  (skatophagia  or  coprophagia).  This  occurs  in 
the  maniacal,  melancholic,  and  the  demented,  and,  of  course,  depends  upon  a 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       81 

grave  disturbance  of  consciousness  and  perversion  of  the  sense  of  taste.  These 
perverse  symi>toms  in  instinctive  life — where  something  which  pliysiologically 
induces  disgust,  and  which  in  itself  is  ideally  horrible,  becomes  the  object  of 
desire — point  more  or  less  directly  to  degeneration  of  the  most  highly  organ- 
ized nervous  elements. 

(B)  Anomalies  of  the  Sexual  Instinct. 

These  anomalies  are  very  important  elementary  disturbances,  since 
upon  the  nature  of  sexual  sensibility  the  mental  individuality  in 
greater  part  depends ;  especially  does  it  affect  ethic,  esthetic,  and  social 
feeling  and  action.  Besides,  abnormalities  of  the  sexual  instinct  lead 
in  many  cases  to  sexual  errors  which  may  become  important  causes 
'of  insanity. 

The  anomalies  of  the  sexual  instinct  may  be  classified  as  follows: 
(a)  It  is  lessened  or  entirely  wanting,  (anesthesia) ;  (h)  abnormally 
increased  (hyperesthesia);  (c)  it  is  perversely  expressed:  i.e.^  when 
the  manner  of  its  satisfaction  is  not  directed  toward  the  preservation  of 
the  race  (paresthesia) ;  (d)  it  manifests  itself  outside  of  the  period  of 
anatomico-physiologic  processes  in  the  generative  organs  (paradoxia). 

(a)  Ancesthesia  Sexualis. — In  this  condition  all  the  organic  im- 
pulses from  the  organs  of  generation,  as  well  as  all  ideas  and  sensory 
impressions,  make  no  sexual  impressions  on  the  individual. 

This  phenomenon  is  present  physiologically  in  the  child  and  the 
aged. 

Pathologically  it  occurs  as  a  congenital  and  as  an  acquired  phe- 
nomenon. There  are  individuals  in  whom  anything  like  sexual  excite- 
ment is  absolutely  wanting,  in  spite  of  normal  development  and  normal 
functions  in  the  organs  of  generation.  Such  eases  are  very  infrequent. 
The  lack  of  function  is  a  symptom  of  degeneration,  like  all  congenital 
anomalies  of  the  vita  sexualis.  More  frequently  anfestliesia  sexualis  is 
acquired:  organically  as  a  result  of  degeneration  of  the  nervous  paths 
and  of  the  genito-spinal  center  (diseases  of  the  spinal  cord),  or  of  de- 
generation of  the  cerebral  cortex  (diffuse  disease  in  the  stage  of 
"  atrophy) ;  functionally,  as  a  result  of  sexual  excesses,  alcoholism, 
hysteria,  and  in  melancholia  and  hypochondria. 

(h)  Hypera^sthesia  Sexualis. — In  this  condition  there  is  abnormal 
impressionability  of  the  vita  sexualis  to  organic,  psychic,  and  sensorial 
stimuli.  Transitions  between  this  and  physiologic  conditions  are 
numerous.  The  immediate  reawakening  of  desire  after  satisfaction  is 
decidedly  abnormal,  especially  when  the  entire  attention  is  taken  by 
it;  and  no  less  so  is  the  awakening  of  libido  at  the  sight  of  persons  or 
things  which  in  themselves  are  sexually  indifferent  (Emminghaus). 
In  this  condition  olfactory  impressions,  which  in  healthy  human  beings 


83  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

liave  no  effect,  and  in  animals  have  an  influence  upon  the  sexual 
instinct,  may  have  an  exciting  influence. 

EareW  excessive  libido  is  porijDherally  induced :  pruritus,  eczema 
of  the  genitals,  genital  neuroses,  etc.  For  the  most  part,  it  is  of  cen- 
tral origin  or  one  of  the  symptoms  of  functional  or  organic  disease- 
processes  affecting  the  cerebral  cortex  (hysteria,  states  of  psychic 
exaltation,  dementia  paralytica  and  dementia  senilis).  In  such  cases, 
however,  the  sexual  instinct  may  be  but  seemingly  intensitied,  since, 
owing  to  the  loss  of  all  healthy  inhibition,  it  is  recklessly  expressed. 
In  cases  where  sexual  and  (equivalent)  religious  delusions  are  con- 
tinually entertained,  the  first  assumption  is  justified. 

States  of  psychic  excitement  in  which  an  abnormally  intensified  instinct 
comes  into  the  foreground  of  the  disease-picture  are  called  satyriasis  in  man 
and  nymphomania  in  ■woman.  The  essential  element  here  is  a  condition  of 
psychic  hyperesthesia  with  intense  implication  of  the  sexual  sphere.  The 
imagination  calls  up  only  sexual  images,  which  may  go  to  the  extent  of 
hallucinations  and  even  true  hallucinatory  delirium.  Everything  calls  up 
sensual  images,  and  the  lustful  coloring  of  ideas  and  apperceptions  is  extreme. 
All  the  feelings  and  impulses  are  controlled  hy  this  powerful  psychoscxual 
excitement.     As  a  rule,  the  genital  organs  are  in  a  state  of  continuous  turgor. 

The  man  affected  with  satyriasis  desires  sexual  gratification  at  any  price, 
and  as  a  substitute  may  abandon  himself  to  onanism  or  sodomy.  The  nympho- 
maniacal woman  seeks  to  attract  men  by  exhibition  or  lustful  gestures,  and 
at  the  sight  of  them  becomes  extremely  excited  sexually  and  may  resort  to 
onanism  or  "imitatio  coitus." 

Satyriasis  is  infrequent;  nymphomania  is  more  common,  and  sometimes 
occurs  in  the  climacteric  and  even  in  senility.  With  great  libido  and  constant 
excitement  of  it,  abstinence  may  induce  these  conditions,  though  only  in  de- 
generate individuals.  These  conditions  also  occur  in  chronic  and  milder  forms, 
leading  men  to  the  grossest  sexual  perversity  and  women  to  prostitution. 

Sexual  hyperesthesia  is  far  from  being  directed  always  to  normal  satis- 
faction of  the  sexual  impulse. 

The  following  may  be  regarded  as  clinical  equivalents  in  women:  Incli- 
nation to  coquetry,  seeking  the  society  of  men,  desire  for  personal  adornment, 
suspicion  of  the  virtue  of  other  women,  inordinate  use  of  pomades  and 
perfumes,  and  constant  conversation  on  the  subject  of  marriage  and  scandals. 
In  the  presence  of  physicians  the  sexual  sphere  is  constantly  alluded  to,  and 
conversation  is  directed  to  the  menses  and  pregnancy;  the  need  of  gynecologic 
examination  is  expressed,  retention  of  urine  is  simulated,  and  in  case  of  neces- 
sary examinations  evidences  of  immodesty  are  manifested.  Religious  excite- 
ment and  the  inclination  to  indulge  excessively  in  religious  devotions  must 
certainly  be  regarded  as  clinical  equivalents. 

The  religious  idea  of  marriage;  the  relation  of  the  church  and  Christ, 
which  is  looked  upon  as  that  existing  between  the  bride  and  bridegroom;  the 
condition  at  puberty,  when  an  emotional  state  of  excitement,  which  is  due  to 
indefinite  sexual  sensations,  are  very  easily  transformed  into  religious  en- 
thusiasm;   the  history  of  the  saints,  detailing  mortifying  of  the  llesh;    and 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.       83 

the  practice  of  certain  sects,  whose  revivals  and  meetings  often  degenerate 
into  horrible  orgies,  are  physiologic  phenomena  which  speak  for  the  inner 
organic  relationship  between  religious  excitement  and  sexual  impulse. 

But  also  in  insanity  this  relationship  is  shown  by  a  gross  mixture  or 
alternation  of  erotic  and  religious  deliria,  frequently  seen  in  maniacal  states. 
Not  infrequently  religious  exaltation  is  accompanied  by  great  sexual  excite- 
ment and  impulse  to  onanism;  onanists  frequently  manifest  religious  delirium, 
expressed  in  ideas  of  mystic  union  with  the  deity  and  corresponding  visions 
and  voices. 

•The  impulse  of  maniacal  girls  to  make  pilgrimages,  to  take  part  in  mis- 
sions, and  to  become  nuns  or  servants  of  priests  (in  which  there  is  much  talk 
of  innocence  and  virginity)  is  something  quite  common. 

(c)  Parcesilicsia  Sexualis. — In  this  condition  the  patient  is  sex- 
ually excitable  to  inadequate  stimuli.  This  anomaly  is  of  the  .greatest 
clinical  and  forensic  importance,  especially  as  it  is  frequently  asso- 
ciated with  sexual  hyperesthesia. 

In  paresthesia  ideas  which  are  normally  colored  with  feelings 
of  displeasure  are  associated  with  feelings  of  libido.  These  become 
so  intense  as  to  reach  the  degree  of  affects.  Then  perverse  sexual  acts 
may  be  expected.  Owing  to  the  simultaneous  presence  of  hyperesthesia, 
ideas  and  perceptions  which  have  not  the  slightest  relation  to  the 
sexual  life  msij  gain  sexual  significance  and  effect.  The  perverse 
sexual  impulse  may  be  directed  (1)  toward  the  opposite  sex  or  (3) 
toward  the  same  sex. 

1.  Perverse  activity  of  the  instinct  for  the  opposite  sex  appears 
in  the  clinical  forms  of  "sadism/''  "masochism/"  and  "feticliismf 

At  the  foundation  of  sadism  there  is  a  physiologic,  though  weakly 
constituted,  association  of  lust  and  cruelty.  Under  pathologic  condi- 
tions this  association  may  be  intensified  bej^ond  measure:  namely, 
when  the  lustful  coloring  of  cruel  ideas  has  reached  the  intensity  of  a 
powerful  affect. 

If  at  the  same  time  the  moral  sense  be  defective,  and  thus  the  jdos- 
sibility  of  opposing  ideas  is  wanting,  the  conditions  for  the  origin 
of  monstrous  acts,  as  a  means  of  satisfaction  of  perverse  sexuality, 
are  present. 

The  performance  of  sadistic  acts  is  essentially  influenced  by  the 
state  of  virility  of  the  sadist. 

If  virility  be  normal,  the  sadistic  impulse  finds  expression  normally,  but 
with  preparatory  or  simultaneous  or  subsequent  maltreatment  of  the  consort, 
which  may  go  to  the  extent  of  murder  ("lust-murder")  ;  and  in  the  latter  case 
the  victim  is  sacrificed,  as  ä  rule,  because  libido  has  not  been  satiated  by  the 
consummated  sexual  act.  As  a  result  of  continued  lustful  excitement  the  mal- 
treatment may  be  carried  further:  hacking  the  body  to  pieces,  wallowing  in 
and  smelling  the  intestines  as  a  result  of  olfactory  and  gustatory  ideas  colored 


84  GENERAL  TATHOLOnY  AND  THERAPY  OF  INSANITY. 

with  lustful  feeling.-^,  carrying  away  portious  of  the  body,  and  anthropophagy. 
If  the  sadist  is  psychically  or  spinally  impotent,  equivalents  are  foimd  in 
choking,  stabbing,  or  whipping  wt)nicn;  or  under  some  circumstances  in  very 
silly  acts  of  violence  toward  women  (symbolic  sadism),  or,  in  their  absence, 
toward  siny  living  object  (whijipiiig  of  schoolboys,  recruits,  pupils,  cruel  treat- 
ment of  animals,  etc.). 

^Masochism  is  tlu'  opposite  of  sadism.  It  depends  upon  lustful 
coloring  of  the  idea  of  Ix-ing  nu'iltroated  by  the  sexual  consort  and  of 
being  entirely  ^\•itlliu  her  power. 

From  this  arises  the  impulse,  accompanied  by  a  powerful  afTect,  to  bring 
about  the  situation  that  gives  pleasure  in  thought;  and,  in  accordance  with 
the  state  of  psychic  and  spinal  potence,  this  is  attempted,  either  as  a  prepara- 
tion or  accompaniment  to  induce  lustful  satisfaction  in  the  act,  or  to  intensify 
it  and  make  it  an  equivalent.  In  this  condition,  in  liarmony  with  the  degree 
of  intensity  of  the  i)erverse  impulse  and  the  remaining  power  of  moral  and 
esthetic  opposing  ideas,  we  meet  a  series  of  acts  extending  from  the  most  dis- 
gusting and  monstrous  to  others  that  are  merely  silly  (seeking  maltreatment, 
insults,  especially  passive  flagellation,  etc.). 

Fetichism  depends  upon  lustful  emotional  coloring  of  ideas  of 
single  portions  of  the  body,  or  of  portions  of  the  clothing  of  women. 
The  pathologic  significance  of  this  manifestation  is  shown  by  the  fact 
that  the  portion  of  the  body  which  has  the  value  of  a  fetich  for  the 
individual  never  has  any  direct  relation  to  sex;  that  all  sexual  in- 
terest is  concentrated  ii})on  a  given  portion  of  a  person  of  the  opposite 
sex;  and  that,  as  a  rule,  in  the  absence  of  the  individual  fetich  the 
normal  sexual  act  is  impossible,  or  at  least  only  possible  with  the  he!]) 
of  corresponding  mental  imageS;,  and  under  such  circumstances  is 
devoid  of  complete  satisfaction. 

But  the  abnormality  of  this  phenomenon  is  shown  with  special 
clearness  by  the  fact  that  the  fetichist  often  finds  the  real  means  of 
sexual  satisfaction,  not  in  the  normal  relation,  but  in  some  manipula- 
tion of  the  part  of  the  body  or  object  which  constitutes  the  fetich. 

The  fetich  varies  with  the  individual.  It  is  always  the  rcsxilt  of  an  acci- 
dental occurrence  which  has  established  the  relation  between  this  single  im- 
pression and  lustful  feeling.  Just  as  within  physiologic  limits  the  hand,  the 
foot,  and  the  hair  have  a  prominent  fetichistic  significance,  so  in  pathologic 
cases  these  portions  of  the  body  are  most  frequently  fetiches.  The  most  im- 
portant factors  in  the  fetichism  of  dress  are  certain  fashions,  colors,  or  por- 
tions of  feminine  attire  (especially  underwear — chemises,  underskirts — and 
handkerchiefs)  that  are  accidentally  during  the  period  of  puberty  brought 
into  association  with  intense  sexual  excitement. 

The  feminine  shoe  is  remarkably  frequent  as  a  fetich,  though,  for  the 
most  part,  it  becomes  so  as  a  result  of  masocliistic  ideas. 


ELE.MENTARY  ANOMALIES  OE  Til  K  CERKLJIAL  E(;N(  TI < )NS.       555 

Finally  there  are  eases  in  wliicli  i/he  fetieh  is  sfniie  pari  iciiiar'  mat(!rial 
(furs,  velvet,  silk)  devoid  of  any  relation  to  sex.  Pathologic  fetich - 
ism  ma.y  lead  to  the  most  extraordinary,  unnatural,  and  even  criminal  acts: 
satisfaction  loco  indehlto,  cutting  off  of  vv^omen's  hair,  theft  of  female  gar- 
ments: handkerchiefs,  chemises,  gloves,  and  silks.  In  these  cases,  as  in  other 
perversions  of  the  vita  sexualis,  it  depends  only  upon  the  intensity  of  the 
perverse  impulse  and  the  relative  strength  of  ethic  opposing  motives  whether 
such  acts  are  committed.  Fetichism  is  also  not  infrequently  the  cause  of 
psychic  impotence. 

In  cases  in  which  sexual  feeling  is  directed  toward  the  same 
sex,  there  is  absence  of  normal  sensibility  for  the  opposite  sex,  while 
inclination  and  instinct  are  directed  toward  the  same  sex  ("contrary 
sexual  instinct" — Westphal).  In  such  cases  the  genitals  are  normally 
developed,  the  glands  are  normal  in  function,  and  the  sexual  type  is 
completely  differentiated. 

When  the  development  of  this  anomaly  of  peculiar  sexual  sensi- 
bility is  complete,  feeling,  thought,  and  activity  do  not  correspond  with 
the  anatomic  and  physiologic  sex  of  the  individual.  In  carriage,  dress, 
and  occupation  this  abnormal  manner  of  feeling  may  be  seen,  and  it 
reaches  the  extent  of  impulse  to  wear  clothing  corresponding  with  the 
sexual  role  in  which  the  individual  conceives  himself. 

This  abnormal  phenomenon  presents  various  degrees  of  develop- 
ment, or  form,  clinically  and  anthropologically. 

1.  With  the  predominant  homosexual  feeling  there  are  traces  of 
heterosexual  sensibility  (psychosexual  hermaphroditism). 

2.  Exclusive  inclination  to  the  same  sex  (homosexuality). 

3.  The  whole  psychic  existence  is  altered  to  correspond  with  the 
abnormal  sexual  feeling  (effemination  and  viraginity). 

4.  The  form  of  the  body  approaches  that  which  is  in  harmony 
with  the  abnormal  sexual  feeling.  However,  there  are  never  actual 
transitions  to  hermaphrodites.  On  the  contrary,  the  genitals  are  com- 
pletely differentiated;  so  that,  just  as  in  all  abnormal  perversions  of 
the  sexual  life,  the  cause  must  be  sought  in  the  brain  (androgyny  and 
gynandry) . 

This  sexual  perversion  is,  as  a  rule,  congenital,  and  as  such  is  observed 
only  in  persons  of  abnormal  constitution.  As  a  rule,  there  is  hereditary  taint, 
frequently  in  the  form  of  some  constitutional  neuropathic  condition  (hysteria, 
neurasthenia).  In  so  far  as  the  activity  of  the  perA^erse  sexual  inclination  is 
restrained  by  social  and  criminal  laws,  the  majority  of  sucli  individuals  be- 
come sexually  neurasthenic,  either  as  a  result  of  onanism  or  abstinence,  with, 
of  course,  the  aid  lent  by  the  degenerate  constitu4ion.  As  a  result  of  the  lat- 
ter and  of  the  neurasthenic  condition,  psychoses  are  not  infrequent  (comp. 
"Etiology").  Very  frequently  contrary  sexual  feeling  is  accompanied  by 
hypersesthesia    sexualis.    Parsesthesia    sexualis    in    its    narrower    sense    also 


Sß  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

occuis,  just  as  in  association  wifh  (Icsoncvate  instinct  for  the  opposite 
M\.  Psydioloifically  the  situation  is  qiiilc  the  same  as  in  the  normal  indi- 
\iiiual.  Love  is  just  as  sensual;  suffering  and  jt-alousy  are  quilo  as  violent 
or  even  more  so,  since  the  subjects  of  this  anomaly  are,  for  tlic  most  part. 
burdtMied.  eooentrio,  and  sexually  abnormally  exacting.  Xutitnr  frigidce  are 
here  \t'ry  iiit"rö((uent  :  i.e.,  iudi\  idiials  tliat  feel  merely  a  sympathy  for  per- 
-niis  ni'  the  same  sfX  or  act  toward  them  platonically.  Eur  the  most  part. 
owing  to  hyperjesthesia.  sexualis,  there  is  lively  desire  fur  sexual  gratiticatioii. 
Persons  of  the  opi)osi1e  sex  may  be  esteemed,  but  only  for  tlicir  intdliTl  u;il 
qualities;    sexual  lelations  witli  them  induce  aversion. 

If  heterosexual  relations  are  forced,  neuroses  are  awakened,  or,  Avhen 
present,  increased  in  intensity.  The  homosexual  wife  submits  to  marital  rela- 
tions; the  homosexual  husband  is  impotent  as  a  result  of  disgust,  wliicli 
operates  as  an  inhibitory  idea  ;  or  he  is  but  temporarily  potent  when  he  suc- 
ceeds in  thinking  of  his  wife  as  some  beloved  male  person. 

Pleasure  and  health  are  possible  for  the  contrary  sexual  individual  only 
in  sexual  relations  with  the  same  sex.  In  woman,  this  is  obtained  in  amor 
leshiciis;   in  man,  in  simple  embrace. 

The  depth  of  congenital  contrary  sexual  feeling  is  shown,  among 
other  things,  by  the  fact  that  the  lustful  dreams  of  such  patients  have  to  do 
with  lascivious  sitiu\tions  with  males  or  vice  versa ;  and  also  by  the  fact  that 
in  the  third  and  fourth  degree  of  sexual  degeneration  the  feeling  of  shame  is 
shown  only  tow-ard  persons  of  the  same  sex. 

Contrary  sexual  feeling  may  also  occur  as  an  acquired  abnormal  phe- 
nomenon, either  episodically  or  lastingl}-.  It  would  seem  that  even  in  these 
cases  a  «taint  were  necessary.  The  exciting  cause  in  my  eases  has  been  neu- 
rasthenia due  to  onanism.  Such  patients  during  the  age  of  possible  procrea- 
tion were  impotent,  experienced  aversion  and  shame  toward  the  opposite  sex, 
reproached  themselves  for  attempts  at  natural  relations,  and  refrained  from 
them.  Intense  libido  and  accidental  associations  led  them  to  sexual  relations 
with  persons  of  the  same  sex  that  were  pleasing  to  them.  Such  cultivated 
cases  of  contrary  sexual  feeling  are  much  inclined  to  active  pederasty. 

(d)  Paradoxia  Sexualis. — In  the  earl}^  3'ears  of  childhood,  and 
therefore  long  before  the  anatomic  development  of  the  organs  of  gen- 
eration, sexual  feelings  and  impulses  may  occur  which  then  lead  to 
'onanism — so  detrimental  to  the  mind  and  body.  Premature  develop- 
ment of  the  sexual  instinct  probably  occurs  only  in  tainted  or  degen- 
erate individuals.  That  irritation  of  the  genitals  in  normal  children 
as  a  result  of  balanitis,  ox3airis,  etc.,  may  lead  to  onanism  is  well  known 
to  neurologists  and  pediatrists. 

Not  infrequently  in  the  aged  whose  vita  sexualis  has  long  become 
extinguished  and  w^hose  genitals  have  atrophied,  there  is  a  reawakening 
of  libido.  This  phenomenon  depends  upon  organic  changes  in  the 
cerebral  cortex  (dementia  senilis).  In  such  cases  impotence  leads  to 
satisfaction  of  libido  in  unnatural  acts  with  children,  in  sodomy,  and 
in  other  horrors  to  which  lowered  moral  tone  and  defective  intelligence 
lend  their  aid. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.      87 

2.  Impulsive  Acts. 

Within  the  domain  of  psychopathology  there  are  acts  the  motives 
of  which  lie  in  ideas  that  are  not  clearly  conscious.  Under  such  cir- 
cumstances the  idea  which  impels  to,  an  act,  even  before  it  has  been 
raised  to  complete  clearness  above  the  threshold  of  consciousness,  is 
transformed  into  the  act,  or  it  never  becomes  perfectly  clear  in  con- 
sciousness. Thus  the  action  appears  to  the  actor  as  it  does  to  a  second 
person, — without  motive  and  therefore  incomprehensible.  It  has  a 
surprising  effect  upon  the  subject 'himself. 

It  appears  as  an  organic  necessity  arising  out  of  the  unconscious 
mental  life,  and  is  comparable  to  a  convulsion  in  the  psychomotor 
sphere. 

Such  an  act  is  immediately  related  to  the  acts  which  result  from 
affects;  it  differs  from  these,  however,  essentially  in  this:  that  it  is 
not  simultaneous  with  an  affect,  even  though  frequently  it  is  not  devoid 
of  an  affective  foundation.  At  least  it  points  to  an  abnormal  excita- 
bility of  the  psychomotor  apparatus,  in  that  here  an  idea  in  a  quasi- 
nascent  state  is  sufficient  in  itself  to  be  transformed  immediately  into 
action  without  the  exercise  of  will  and  consciousness. 

Such  a  phenomenon  in  the  highly  organized  sphere  of  the  central 
nervous  system  seems  to  indicate  a  low  degree  of  activity  of  a  mechan- 
ism capable  of  higher  functions,  and  it  gives  rise  to  a  suspicion  of  a 
degenerate  foundation;  in  fact,  these  impulsive  acts  occur  only  in 
degenerate  insanity  (Morel). 

Most  prominent  here  are  the  hereditary  degenerate  cases,  espe- 
cially those  occurring  in  relation  to  the  hysteric  and  epileptic  neuroses, 
and  those  that  have  been  acquired  by  drink,  onanism,  and  grave  injury 
to  the  brain  (trauma  capitis). 

The  psychic  energies  which  impel  to  action  are  lively  organic  feel- 
ings, especially  those  of  a  sexual  kind  which  often  appear  in  perverse 
form,  and  lead  to  violation,  with  murder  and  mutilation  of  the  victim, 
and  even  to  anthropophagy;  or  they  are  affective  emotions  (depres- 
sion, weariness,  homesickness),  not  infrequently  induced  and  intensi- 
fied by  a  disturbed  state  of  general  feeling,  neiiralgia,  etc.,  which  call 
up  annihilating  impulses  that  may  be  directed  either  against  others 
or  against  self. 

At  the  instant  of  the  deed  the  idea,  though  previously  dark,  may 
come  like  a  stroke  of  lightning  in  the  form  of  an  imperative  hallu- 
cination or  a  vision  of  blood,  red  flames,  and  the  like;  enter  con- 
sciousness ;  and  become  the  directing  force  to  an  act,  such  as  burning, 
murder,  etc. 


88  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

In  other  cases  the  organic  impulse  (sensual  feeling)  awakens  an 
inherited  or  acquired  impulse  and  leads  to  its  logical  expression  (klep- 
tomania, drunkenness,  etc.)  (Schule). 

Such  impulsive  acts,  of  which  perverse  sexual  acts — rape,  suicide, 
murder,  and  arson  are  the  most  important,  classified  witli  those  due  to 
melancholic  despair,  to  imperative  ideas,  or  to  maniacal  iuipulses  that 
are  pathologically  intensified  or  heyond  inhibitory  control — have 
afforded  the  material  for  the  creation  of  the  erroneous  theory  of 
so-called  monouianias. 

3.  Psychomotor  Disturbances. 

These  are  motor  acts  which  possess  all  the  features  of  voluntary 
acts,  or  which  at  least  have  their  origin  in  the  psychomotor  centers  of 
the  brain,  but  arise  without  the  influence  of  the  will  and  depend  upon 
inner  organic  irritative  processes. 

(a)  Tlie  Impulsive  Restlessness  of  the  Maniacal. 

At  the  height  of  mania  the  patient  is  in  constant  motion.  He 
talks,  sings,  cries,  dances,  jumps,  and  destroys  everything  in  reach  until 
he  is  temporarily  exhausted.  These  movements  are  apparently  vol- 
untary; they  seem  to  be  true  voluntary  acts,  but  close  observation 
shows  that  they  are  devoid  of  the  influence  of  the  will  and  result 
without  consciousness  of  purpose, — indeed,  even  without  conscious- 
ness at  all;  they  have  the  character  of  automatic,  impulsive,  forced 
movements. 

The  cause  of  these  movements  is  not  clearly  conscious  ideas  that 
have  a  root  in  mental  interest  or  sensory  perception,  and  thus  impel 
to  an  act ;  but  here  we  have  to  deal  with  direct  inner  organic  processes 
affecting  the  psychomotor  centers,  which,  owing  to  the  greatly  increased 
ease  of  psychic  activit}^,  are  transformed  into  movements,  without  the 
motives  of  movement  becoming  clear  ideas  in  consciousness. 

This  kind  of  movement  is  purely  automatic,  though  it  seems  to  be 
voluntary,  because  the  stimulus  affects  a  sphere  of  the  psychic  organ, 
which  under  normal  circumstances  is  accustomed  to  react  only  to 
voluntary  impulses. 

There  can  no  longer  be  any  doubt  that  the  impulse  to  movement  in  the 
maniacal  is  an  irritative  phenomenon  in  the  sensorimotor  cortical  areas  of  the 
forebrain,  which  has  nothing  -whatever  to  do  with  volition.  There  is  a  differ- 
ence of  opinion  only  concerning  the  significance  of  the  process,  either  as  a 
sensory  or  a  motor  irritative  phenomenon. 

Mendel  thinks  that  the  motor  centers  are  in  a  state  of  increased  irritabil- 
ity, so  that  the  slightest  stimulus  induces  intense  and  extensive  reaction 
(motiveless  muscular  movements) ;    Meynert  regards  the  symptoms  as  an  irri- 


ELEMENTARY  ANOMALIES  OF  THE  CEREURAL  FUNCTIONS.       ßo 

tative  i)lic'iioinonon  uf  a  ftcDsoii-lialliiciiuilory  cliaractei'.  J>y  liiiii  llic  iiiipulsc 
to  movement  in  the  maniacal  is  looked  upon  as  induced  by  hallucinations  of 
the  muscle-sense  and  by  hallucinatory  feelings  of  innervation.  According  to 
him,  the  areas  for  the  feelings  of  innervation  (the  sensorimotor  cortical  areas 
of  the  forebrain,  which  withont  doubt  contain  memory-pictures  and  ideas  of 
movements)  are  affected  by  li;illiicinaiions.  According  to  this  theory,  the 
impulse  to  movement  could  not  be  especially  motor,  but  a  sensory  ii-ritation. 
Meynert  bases  his  opinion,  which  is,  at  any  rate,  justified,  upon  tlic  facts  that 
all  movements  may  be  ultimately  referred  to  sensation,  and  that  tlie  coilical 
cells  have  but  one  functional  peculiarity:    the  capability  of  sensaticjii. 

Under  all  circumstances  the  impulse  to  movement  in  the  maniacal  is  the 
product  of  excitement  which  results  from  the  abnormal  process  going  on  in  the 
psychic  organ,  and  therefore  it  is  not  functionally  and  psychologically  induced  ; 
thus  it  is  analogous  to  primordial  delusions,  imperative  ideas,  hallucinations, 
and  abnormal  states  of  feeling  that  are  not  caused  by  external  events. 

The  abnormal  organic  process  calls  up  memory-pictures  of  -earlier  move- 
ments, which,  because  of  their  organic  physiologic  origin,  are  especially  in- 
tense. The  area  of  the  cerebral  cortex  that  is  abnormally  excited  reacts  with 
the  greatest  ease  to  irritation  (idea  of  movements),  and  transforms  it  imme- 
diately into  a  corresponding  muscular  act ;  and  that  the  easier,  since  in  the 
.  psychic  mechanism  of  the  maniacal  all  possibility  of  inhibition  has  been 
removed. 

It  was  formerly  generally  supposed  that  the  maniacal  person 
developed  more  muscular  power  than  one  in  the  physiologic  state^  as 
a  result  of  which,  to  the  detriment  of  the  unfortunate  patients  who 
were  therefore  the  more  feared,  they  were  loaded  with  chains  and 
kept  in  prisons. 

This  opinion  is  physiologically  untenable.  It  is,  indeed,  true  that  the 
maniacal  patient  sometimes  performs  acts  of  strength  which  a  healthy  person 
seems  incapable  of;  but  this  OA^erproduction  of  muscular  power  is  only  ap- 
parent. This  is  to  be  explained  by  the  recklessness  of  the  patient,  who  in  his 
disturbed  state  of  consciousness  perceives  no  danger,  no  feeling  of  dizziness  or 
fatigue,  and  is  therefore  capable  of  using  up  all  his  muscular  power;  just 
as  a  healthy  person  in  a  state  of  despair,  or  in  the  face  of  death,  may  per- 
form unusual  feats  of  strength.  However,  if  the  absolute  amount  of  strength 
is  not  increased,  still  the  duration  of  muscular  activity  far  exceeds  that  which 
is  normally  possible.  A  maniacal  patient  is  capable  of  jumping,  dancing,  run- 
ning about,  and  storming  all  day  long  without  getting  tired,  unless  he  be  over- 
come by  exhaustion;  a  simulator  cannot  keep  this  up  an  hour.  The  reason 
for  this  is  that  in  the  truly  maniacal  there  arises  no  feeling  of  fatigue  (mus- 
cular anesthesia,  disturbed  apperception  in  the  organ  of  consciousness) ;  but 
especially  because,  while  in  the  normal  individual  all  these  acts  and  movements 
luust  be  called  up  by  the  will,  in  the  maniacal  the  Avill  is  excluded  and  the  acts 
are  a  product  of  spontaneous  excitation. 

Should  the  result  (muscle-work)  be  the  same,  still  there  is  a  great  differ- 
ence in  the  two  cases,  whether  activity  of  the  central  nervous  system  is  a 
voluntary  psychic  phenomenon  or  a  spontaneous  and  automatic  process.  We 
see  the  same  thing  in  the  hysteric,  hystero-epileptic,  and  choreic,  who  all  day 


90  GENERAL  PATTTOLOOY  AND  TPIERAPY  OF  INSANITY. 

kmg  ONpi'iiil  nnwiiiliir  strengt  li  in  tlio  form  of  convulsive  movenionts  williout 
becoming  tired  or  exhausteil.  Appnreutly,  voluntary  ana  spontaneous  mus- 
cular activities  are  not  identical;  and  it  would  seem  that  it  requires  many 
mechanical  spontaneous  expenditures  of  force  to  be  equivalent  to  one  act  that 
is  psychic. 

This  is  a-lso  shown  in  trophic  relations,  in  that  the  maniacal  patient,  in 
spite  of  constant  movement  for  weeks  at  a  time,  in  spite  of  sleeplessness,  in- 
sufficient nourishment,  and  increased  loss  of  body-heat,  does  not  suffer  the 
same  loss  of  weight  that  the  healthy  person  must  suffer  under  approximately 
similar  conditions  of  activitj-. 

(b)  Psydiic  Reflex  Acts  in  Melancholies  and  the  Delirious. 

Fundamentally  different  from  this  impulse  to  movement  in  the 
maniacal,  though  outwardly  corresponding  with  it  for  the  most  part, 
is  the  excessive  movement  seen  in  certain  pliascs  of  melancholia 
(activa)  and  in  the  delirious.  The  melancholic  patient  also  under 
some  circumstances  destroys  and  raves,  but  his  activity  is  psychic 
reflex  movement,  conditioned  by  painful  states  of  feeling,  esjiecially 
precordial  distress;  and  therefore  the  intensity  of  movement  is  abso- 
lutely ck'pendent  upon  the  intensity  of  the  emotional  state.  This 
motor  unrest  in  the  melancholic  and  delirious,  owing  to  its  reflex- 
origin  in  painful  states  of  feeling  and  in  couscious,  frightful  liaikicina- 
tions  and  deliria,  differs  from  the  purely  automatic  action  of  the 
maniacal;  it  is  analogous  to  the  acts,  often  purposeless  and  destruc- 
tive, that  are  committed,  as  it  were,  instinctivel}^,  by  those  enduring 
torture,  as  a  result  of  the  physiologic  affect  of  despair,  in  order  to  bring 
about  a  lessening  of  inner  tension  and  thus  experience  a  diminution 
of  painful  states  of  feeling. 

(c)  Imperative  Movements  in  States  of  Mental  Weahness. 

Certain  imperative  movements  are  not  to  be  confounded  witli  the 
phenomenon  of  the  maniacal  impulse  to  movement.  These  are  ob- 
served in  states  of  mental  weakness.  In  the  first  place,  the  uniformity 
of  these  movements  prevents  such  an  error.  They  are  of  a  combined 
nature  (striking  oneself,  walking,  pulling,  rubbing,  etc.),  repeated 
interminahly,  and  the  individual  seems  absolutely  unconscious  of 
them.  Originally  they  are  probably  awakened  by  sensations,  delusions, 
or  hallucinations,  and  voluntarily  performed;  hut  gradually  they 
hecome  a  hahit,  and,  with  the  disappearance  of  the  original  conscious 
impulse  which  induced  them,  they  are  automatically  continued;  just 
as  are  certain  peculiar  movements  like  associated  movements  and 
gestures  in  the  sane,  which,  once  acquired,  finally  hecome  a  second 
nature:   i.e.,  unconscious. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.      91 

(d)  Tetany. 

In  this  condition  the  muscles  are  teuse,  in  a  state  of  slight  flexor 
contracture,  which,  when  the  patient  is  taken  hold  of,  as  must  be  done, 
owing  to  the  state  of  passivity,  is  increased  until  the  resistance  offered 
is  enormous;  and  this  can  only  be  overcome  by  the  exertion  of  n  cer- 
tain amount  of  force  on  the  part  of  the  examiner.  Of  course,  tli*; 
patient  offers  some  active  resistance  to  such  attempts  to  carry  out  pas- 
sive movements,  but  he  is  scarcely  conscious  of  this  resistance,  which 
may,  in  some  cases,  be  due  to  the  cloudy  inimical  or  painful  impressions 
derived  from  the  external  world. 

This  phenomenon  is  always  limited  to  the  flexors,  adductors,  and 
pronators ;  the  extensors  are  never  affected. 

As  most  appropriately  described  by  Arndt,  at  the  height  of  this  condition 
the  patient  is  drawn  up  into  a  ball,  with  head  bent,  knees  pressed  on  the 
chest,  back  curved,  shoulders  dra\vn  tight  together,  the  upper  arms  pressed 
to  the  sides  and  the  forearms  to  the  chest,  and  even  the  nails  are  pressed  into 
the  palms.  The  thighs  are  pressed  together  and  held  close  to  the  abdomen, 
the  legs  bent  up  to  the  thighs.  Along  with  this  there  is  a  tense,  painful  mien, 
wrinkled  eyebrows,  contracted  and  protruding  lips,  with  the  folds  of  the  chin 
pressed  together.  This  is  the  classic  picture.  Frequently  only  the  facial 
muscles  and  the  flexors  of  the  head,  or  of  the  hands  and  fingers,  are  affected. 
Unquestionably  here  there  is  an  irritation  in  the  psychomotor  centers; 
Avhether  it  is  direct  or  the  result  of  a  sensory  reflex,  as  Schule  supposed, 
remains  undecided. 

This  tetany  occurs  in  melancholia  and  in  states  of  dementia  fol- 
lowing it,  and  always  indicates  severe  irritative  processes  and  grave 
states  of  disease.  In  pronounced  and  lasting  cases  there  is  always  a 
a  deep  disturbance  of  consciousness  and  apperception. 

(e)  Catalepsy. 

In  this  condition  the  muscles  do  not  exhibit  the  rigidity  and 
contracture  seen  in  tetany.  They  offer  no  resistance  to  passive  move- 
ment, but  maintain  for  a  long  time  the  position  originally  taken  or 
imparted  to  them. 

The  patient  is  not  capable  of  changing  his  position  voluntarily; 
it  is  ,the  gradual  effect  of  the  weight  of  the  limbs  which  finally  brings 
them  into  another  position.  Here  the  limbs  may  exhibit  that  peculiar 
wax-like  flexibility,  as  a  result  of  which,  like  a  wax  figure,  they  main- 
tain the  position  in  which  they  are  placed  (catalepsy  vera)  ;  or  the 
fingers,  after  being  bent,  snap  back,  as  it  were,  into  the  extended  posi- 
tion (catalepsy  spuria). 


93  GENERAL  PATllüHXJY  AND  TllKl^XPY  OF  INSANITY. 

The  cataleptic  eoiulition  occurs  as  an  aUack  and  is  transitory,  or  it  is 
continuous.  In  the  latter  case  it  is  always  associated  with  a  deep  disturl)ani.e 
of  consciousness.  In  the  cataleptic  state  there  is  cutaneous  and  muscular 
anesthesia.  The  lack  of  muscular  feeling  combined  with  the  disturbance  of 
consciousness  removes  the  sensation  of  pain  from  fatigue,  and  thus  makes  it 
possible  for  tli'e  patient  to  remain  in  the  most  uncomfortable  position. 
Nevertheless,  owing  to  the  fact  that  with  the  actual  absence  of  consciovis 
innervation  the  limb  does  not  innnediately  obey  the  law  of  gravity,  there  is  an 
indication  of  an  automatic  or  reflex  continuous  innervation  of  the  cataleptic 
muscles  which  lias  its  origin  somewhere  in  the  eerebro-spinal  path  (tegmen- 
tiun).     Probably  strong  peripheral  sensory  stimuli  induce  the  cataleptic  state. 

Schule  looks  upon  the  phenomenon  as  a  reflex  inhibition  in  the  psj'cho- 
motor  sphere,  conditioned  by  efl'ectual  (principally  sexual)  sensory  stimuli,  in 
connection  with  weakened  cortical  function  (great  brain  anemia),  and  also 
associated  with  a  neuropathic  constitution,  due  to  heredity,  onanism,  uterine 
disease,  etc. 

Cataleps}'  also  points  to  an  intense  degree  of  the  disease  when  the 
mind  is  affected.  It  occurs  in  the  mekncholic,  hysteric,  and  epileptic; 
also  in  mania  and  dementia. 

4.  Disturbances  of  the  Will. 

The  spliore  of  the  will  presents  many  al)normal  ])henni)iona  in  the 
insane,  which  necessarily  result  from  the  abnormal  feelinos  and  emo- 
tions, and  from  the  anomalies  of  thought,  both  in  its  formal  processes 
and  its  content. 

First  must  be  mentioned  the  seemingly  anomalous  fact  that  the 
insane  frequently  speak  rationally,  or  at  least  without  rovoaling  any 
delusion,  and  still  commit  the  most  nonsensical  acts,  whicli  they  are 
callable  of  excusing  with  ingenuity.  The  frequency  of  such  cases  has 
led  to  the  classification  of  them  as  so-called  reasoning  insnnit!/. 

The  explanation  of  this  peculiar  phenomenon  is  the  following:  Tliere  is 
no  delusion,  but  the  process  of  thought  is  formally  disturbed.  It  is  in  some 
way  so  increased  that  no  reflection  is  possible  concerning  the  concrete  act  to 
w  hich  an  idea  gives  rise.  This  is  the  case  in  the  maniacal.  Any  thought  is  at 
once  expressed  in  the  corresponding  act, — i.e.,  -without  having  been  tested  and 
compared  with  opposing  motives, — and  therefore  the  act  must  necessarily  have 
the.  character  of  thoughtlessness  or  haste.  Afterward  the  patient  is  able  to 
excuse  the  act  which  he  himself  sees  to  be  unusual,  and  thus  he  gives  a  reason- 
able motive  for  it;  and,  owing  to  his  abnormal  intensity  of  thought,  he  is 
never  embarrassed.  In  other  cases  the  perverted  act  is  the  result  of  an  im- 
perative idea,  the  transformation  of  which  into  an  act  the  patient  is  no  longer 
able  to  prevent;  or  the  patient  is  in  such  an  emotional  state  that  ideas  no 
longer  enter  consciousness  with  perfect  clearness,  or  at  least  are  no  longer  sub- 
ject to  reflection  (psychic  reflex  acts,  impulsive  acts). 

In  many  cases  of  apparently  undisturbed  intelligence  where  perverted 
acts  are  manifest,  full  intelligence  exists  only  in  api)earance.     There  are  de- 


ELEMENTARY  ANOMALIES  OF  THE  f-'ET^EBRATv  I'TTNCTTON.S.       93 

lusional  ideas  that  form  the  motive  of  peivorted  acts,  but  the  pationt  is  able 
to  conceal  or  dissimulate  them.  For  this  reason,  then,  the  kind  and  man- 
ner of  volition  and  action  of  a  patient  are  diagnostically  important,  since  they 
may  indicate  other  elements  of  disease. 

That  the  insane  are  able  to  act  with  design  and  reflection  is  a  matter  of 
surprise  to  the  laity;  but  it  is  due  simply  to  the  fact  that  the  logical  mechan- 
ism of  judgment  is  still  at  the  command  of  the  patient  as  long  as  general  loss 
of  psychic  functions  has  not  occurred  (confusion,  dementia). 

In  insanity  the  M'ill  can  be  abnormally  changed  only  in  two  ways. 
It  may  be  lessened  to  the  extent  of  absolute  absence  of  it,  or  it  may  be 
increased  beyond  all  limit. 

(a)  Conditions  of  Diminished  Volition  occur  in  dements  and 
in  melancholies.  In  the  former  such  conditions  are  the  sad  result  of 
loss  of  all  mental  and  ethic  interest,  and  of  emotional  indifference  and 
diminished  sensory  apperception.  In  such  cases — for  example,  in  apa- 
thetic dementia- — there  may  be  even  complete  loss  of  ideas.  Under 
such  circumstances  there  must  also  necessarily  be  an  end  of  volition. 
There  remain  only  the  functions  of  instinctive  life,  and  even  these 
may  become  limited  to  the  satisfaction  of  appetite  for  food  (abulia) . 

The  lack  of  volition  in  melancholies  (anenergy),  though  it  be  an 
external  passive  expression  exactly  like  that  of  the  dement,  has  an 
entirely  different  foundation.  It  is  possible  that  in  these  cases  there 
is  virtually  a  very  lively  will,  but  its  expression  is  impossible  owing  to 
the  multitude  of  inhibitory  influences.  These  may  depend  upon  the 
following : — 

1.  Consciousness  of  the  im-possihility  of  attaining  that  ivhich  is 
desired.  Abolition  is  a  conscious  desire  in  which  that  which  is  wished 
for  is  thought  of  as  unconditionally  attainable.  The  melancholic  in 
his  state  of  lowered  sense  of  self,  his  changed  general  feeling  (weak- 
ness), puts  no  more  trust  in  his  power  to  attain  what  he  wishes,  and 
therefore  ceases  to  entertain  desires. 

2.  Feelings  of  displeasure.  The  psychic  activity  necessary  for 
action  is  associated  in  the  patient  with  psychic  pain  and  unpleasant 
feelings;  therefore  mental  activity  ceases;  just  as  in  cases  of  physical 
pain,  like  neuralgia,  the  sufferer  instinctively  avoids  moving  the 
affected  part. 

3.  Peculiar  inhibition  of  the  psychic  mechanism.  There  is  an 
increased  difficulty  in  the  transformation  of  ideas  into  motor  acts  which 
may  be  looked  upon  as  inhibited  activity  in  the  psychic  reflex  arc,  or  as 
an  increased  reflex  inhibition.  Under  such  circumstances  the  idea  is 
not  powerful  enough  to  act  as  a  motor  stimulus.  The  patient,  in  whom 
one  sees  how  painful  this  inhibited  state  of  psychic  tension  is,  makes 
every  effort  to  c'Erry  out  the  desired  movement,  but  he  does  not  succeed, 


94  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

or  only  imperfectly,  in  performing  it.  In  states  of  violent  emotion 
(intensification  of  the  stimulating  influence  of  ideas),  however,  the 
motor  sphere  is  temporarily  free,  and  in  his  acts  the  patient  is,  per- 
haps, even  more  wild  and  stormy  than  the  maniac. 

4.  Disturhances  of  association.  Sometimes  in  the  melancholic 
the  lack  of  volition  is  nothing  but  lack  of  decision,  depending, upon 
contradictory  ideas  which  continually  inhibit  and  disturb  the  idea 
which  impels  to  action.  The  patient,  impelled  first  in  this  direction 
and  then  in  that  by  the  increasing  and  decreasing  effect  of  opposing 
ideas,  is  unable  to  come  to  any  decision,  and  becomes  involved  in 
constant  doubt. 

5.  Finally  there  are  cases  where  the  will  is  disturbed  in  its  expres- 
sion merely  as  a  result  of  delusions  or  hallucinations.  Tlius,  for  exam- 
ple, a  patient  may  stand  in  one  spot  because  he  has  the  delusion  that 
his  legs  are  made  of  glass  or  wood;  or  because  he  thinks  he  is  standing 
on  the  edge  of  an  abyss ;  or  because  voices  have  commanded  him  not  to 
move  or  speak,  or  he  will  be  lost. 

(I)  UNLIMITED  INCREASE  OF  VOLITION  (liyperbulia — Emming- 
haus)  is  found  in  maniacal  states.  The  causes  of  this  are  to  be  looked 
for  in  the  following  conditions : — 

1.  In  the  abnormally  increased  feeling  of  self,  which  induces  con- 
tinuous excitation  arising  out  of  the  feeling  of  increased  physical  and 
mental  capabilities,  and  makes  everything  seem  attainable. 

2.  In  the  loss  of  all  inhibitory  regulating  and  controlling  ideas 
of  use  and  purpose,  which  in  states  of  quiet  emotion  and  moderate 
activity  of  thought  are  always  at  the  command  of  the  sane  and  control 
their  voluntary  acts. 

3.  Owing  to  the  pathologically  intensified  change  of  ideas  and  the 
facilitated  association  of  them,  there  is  an  abundance  of  motor  motives 
which  contrasts  with  the  monotony  of  thought  and  the  slowness  of 
association  in  melancholies.  These  ideas  are  also  extraordinarily  col- 
ored by  intensity  of  feeling. 

4.  But  also  the  transformation  of  ideas  into  motor  impulses  is 
decidedly  facilitated.  This  is  shown  in  the  great  ease  and  promptness 
with  which  the  motor  apparatus  reacts  to  motor  motives. 

This  pathologic  phenomenon-  may  be  regarded  as  a  facilitated 
expenditure  of  the  tension  relations  of  ideas — as  an  increased  impres- 
sionability of  the  psychic  organ.  But  it  is  also  conceivable  tbat  this 
increased  reflex  excitability  could  arise  only  from  the  diminution  or 
absence  of  a  reflex  inhibitory  influence,  exercised  by  higher  centers 
which  subserve  the  processes  of  reasoning  reflection,  upon  certain 
psychomotor  centers;   just  as  the  spinal  cord  is  suljjoct  to  the  inhibi- 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.      95 

tory  influence  of  the  cerebral  hemispheres,  and  an  increased  reflex 
excitability  occurs  when  this  influence  is  lessened  by  sleep  or  abnormal 
cerebral  conditions. 

Owing  to  this  disturbance  of  the  will,  the  acts  of  the  maniacal 
seem  to  lack  reflection,  and  appear  strange,  foolish,  or  whimsical. 

5.  Disturbances  of  ''Free"  Will. 

Insanity  removes  the  possibility  of  free  will.  This  fact  is  recog- 
nized by  the  laws  of  all  civilized  nations. 

Free  will  is  impossible  in  the  insane  for  the  following  reasons : — • 

(a)  As  a  result  of  brain  disease ;  and  therefore  as  a  result  of  or- 
ganic causes,  spontaneous  affects,  passionate  feelings,  impulses  and 
desires,  delusions,  and  errors  of  the  senses  become  causes  of  acts. 

(b)  Because  the  motives,  no  matter  how  they  may  have  arisen, 
which  impel  to  an  act  are  unopposed  by  any  moral  or  legal  restraining 
ideas;  since  (1)  the  latter,  as  a  result  of  the  brain  disease,  like  otlier 
higher  psychic  powers,  are  either  lastingly  lost  (states  of  mental 
weakness)  or  are  temporarily  wanting  (transitory  disturbances  of  self- 
consciousness)  ;  or,  (2)  owing  to  the  formal  disturbance  of  thought  as 
a  result  of  disease,  they  cannot  enter  consciousness  (melancholia, 
mania) . 

(c)  Because  subjective  and  objective  consciousness  is  falsified 
by  delusions  and  hallucinations.  This  disturbance  may  go  so  far  that 
the  whole  former  personality  is  changed  into  a  new  and  abnormal  per- 
sonality (paranoia)  ;  so  that  the  action  is  that  of  a  psychic  personality 
entirely  difl^erent  from  the  previous  personality  of  the  individual — 
legally  the  person  is  the  same,  but  psychologically  he  has  become 
another. 

CHAPTER  V.  » 

Disturbances  of  Consciousness. 

Consciousness,  which  is  made  up  of  the  content  of  ideas  present 
in  it  in  a  given  unit  of  time,  is  not  a  constant  quantity.  In  accord- 
ance with  the  degree  of  clearness  of  ideas  there  are  various  degrees 
of  clearness  of  consciousness. 

The  highest  degree  of  consciousness  is  represented  by  so-called 
'self -consciousness :  i.e.^  a  condition  in  which  the  thinking  individual 
is  completely  conscious  of  his  thinking  activity.  It  presupposes  the 
simultaneous  existence  of  undisturbed  sensory  perception  subject  to 
the  will  (attention)  ;  and  of  undisturbed  reproduction  from  the  store- 
house of  memory.     Since  the  ego  is  clearly  conscious  of  the  processes 


96  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

that  are  taking  place,  it  involves  consciousness  of  personality;  since 
ideas  always  occur  with  reference  to  a  sense  of  space  and  time,  it  also 
involves  world  or  space  consciousness  and  consciousness  of  time. 

x\long  with  this  world  of  self-conscious  mental  life,  and  connected 
with  it  by  many  transitions,  there  is  an  unconscious  psychic  life  that 
is  infinitely  more  extensive  and  iiuportant  than  the  conscious  mental 
sphere. 

This  unconscious  sphere  of  psj-cliic  life  is  continuously  in  activity;  it 
elaborates  into  feelings  the  stimuli  ^Vhicll  the  sensory  nerves  from  all  parts  of 
the  body  bring  to  the  cerebral  cortex;  it  regulates  the  movement  (locomo- 
tion) initiated  by  an  act  of  self-consciousness  (Avill),  and  makes  it  possible  for 
the  act  to  be  carried  on  automatically  quite  as  promptly  and  certainly  as 
wiien  guided  bj-  the  will. 

It  elaborates  the  ideas  excited  physiologically  by  the  processes  of  nutri- 
tion and  tissue-change  in  the  ganglion-cells  of  the  cortex,  to  thoughts,  im- 
pulses, etc.,  and  complicated  psychic  processes,  the  complete  result  of  which 
presents  itself  to  self-consciousness  in  the  form  of  opinions,  judgments,  and 
emotions. 

It  is  to  this  unconscious  activity  that  we  owe  our  mental  individuality, 
our  psychic  disposition,  our  ideas  and  impul.ses.  It  is  infinitely  more  impor- 
tant than  the  activity  of  our  self-conscious  ego.  Under  pathologic  conditions 
it  may  happen  that  this  activity  of  the  unconscious  brain  mechanism,  whether 
it  be  in  the  form  of  sensory  reproduced  ideas  or  in  motor  impulses,  does  not 
reach  consciousness  (it  remain.s,  then,  unconscious)  ;  or  it  is  appcrceived  in 
some  roundabout  way,  as  in  hallucinations,  or  as  a  completed  impulsive  act. 

The  cause  of  this  disturbance  lies  in  abnormal  changes  in  the  organ  of 
consciousness,  which  may  even  go  to  the  extent  of  absence  of  the  functions 
which  belong  to  it   (attention,  reflexion,  voluntary  reproduction,  olc). 

Then  the  activity  of  the  imconscious  brain  mechanism  is  absolutely  lost 
to  self-consciousness — afterward  the  individual  knows  absolutely  nothing  of 
what  he  has  thought  or  what  has  happened  (amnesia)  ;  in  other  cases  self- 
consciousness  is  able  to  recognize  nothing  of  the  manner  of  origin  of  what  has 
been  unconsciously  done — it  seems  to  be  something  which  belongs  to  another 
ego  (division  of  personality  as  it  occurs  in  demonomania  and  paranoia),  or  as 
something  that  has  been  called  up  in  the  external  world  (iiallucinalious  wliicli 
are  not  recognized  as  such). 

This  activity  of  the  unconscious  sphere  may  be  congruentl}" 
combined,  and  consist  of  hallucinations,  delusions,  and  complicated 
acts,  and  thus  seem  to  resemble  the  ordinary  manner  of  expression  of 
self-conscious  life.  However,  that  it  was  not  self-conseiqus  is  proved 
by  the  amnesia  which  exists  afterward  for  all  these  unconscious  acts; 
for  it  is  only  those  psychic  activities  which  take  place  in  the  sphere 
of  self -consciousness  which  leave  behind  them  traces  of  historic  con- 
sciousness :  i.e.,  memory, 

■A  great  number  of  symptoms  which  occur  in  insanity  (many  feel- 
ings, affects,  delusions,  acts,  and  hallucinations)  are  only  to  be  under- 


ELEMENT AKY  ANOMALIES  OF  THE  CEREBRA L  FUNCTIONS.       97 

stood  with  the  assumption  that  they  are  unconscious  products  of  the 
spontaneous  brain  mechanism  which  have  either  not  been  illuminated 
by  the  light  of  self -consciousness  or,  if  this  has  occurred,  were  not  recog- 
nized as  due  to  unconscious  activity  of  the  personal  psychic  mechanism. 

In  insanity  disturbances  of  consciousness  play  a  most  important 
role,  since  they  cause  grave  defects  in  the  patient^s  power  of  criticism 
of  the  emotional  states,  dcliria,  subjective  perceptions,  etc.,  due  to  the 
disease-process,  and  tlius  lead  the  patient  into  delusion  and  error, 

A  disturbance  of  consciousness  as  an  integral  function  of  the  cere- 
bral cortex  is  to  be  expected  in  every  psychosis.  In  fact,  this  is  the 
constant  characteristic  in  the  play  and  clinical  abundance  of  symptoms. 
In  every  empirically  true  picture  of  psychic  disturbance,  and  included 
in  the  combination  of  elementary  disturbances,  there  must  be  a 
peculiar  kind  of  disturbance  of  general  self-consciousness,  in  accord- 
ance with  the  peculiar  manner  in  which  the  psychic  processes  have 
been  subjected  to  losses,  inhibitions,  etc.  Thus,  in  this  sense,  one 
may  speak  of  melancholic,  maniacal,  and  paranoiac  states  of  con- 
sciousness (vide  "Special  Pathology"). 

The  abnormal  changes  of  consciousness  of  personality  are  of  the 
greatest  clinical  interest. 

Thus,  we-  meet  grave  disturbances  of  consciousness  of  time  and 
place,  which  bring  about  a  cloudy  mental  existence,  in  severe  degen- 
erative brain  diseases  (dementia  paralytica  and  dementia  senilis). 

There  are  patients  in  whom  the  previous  healthy  period  of  their 
lives  has  quite  disappeared  from  consciousness,  or  at  least  seems  to 
belong  to  another  personality;  so  that  the  patient  dates  his  existence 
only  from  the  time  of  the  beginning  of  his  disease,  or  from  a  particular 
date  during  the  disease  (origin  of  a  new  ego  representing  the  delu- 
sions). 

Indeed,  there  are  cases  where  consciousness  of  personal  psychic 
existence  entirely  disappears,  and  the  patient  looks  upon  himself  as  an 
object,  and  therefore  speaks  of  himself  in  the  third  person.  In  such 
cases,  along  with  the  psychic  transformation,  there  are  profound  dis- 
turbances of  general  sensibility,  anesthesias,  which  not  infrequently 
give  rise  to  the  delusion  of  being  dead. 

Still  more  interesting  are  those  cases  in  which,  along  with  the 
abnormal  ego,  fragments  of  the  former  personality  have  been  re- 
tained; or  in  which  the  latter  has  been  broken  uj),  as  it  were,  into 
several  personalities  that  are  subject  to  the  dominate  circle  of  false 
ideas  (multiple  ego,  division  of  the  personality). 

In  the  latter  case  there  still  exists  at  least  a  continuity  of  con- 
sciousness which  is  only  changed  in  content;  there  are  not  two  persons. 


98  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

but  it  is  the  same  individual  having  different  circles  of  ideas.  The 
various  egoes  are  still  necessarily  held  together  by  the  unity  of  body- 
sensibility  and  the  consciousness  of  the  continuous  series  of  the  psychic 
phenomena  in  time. 

In  some  rare  cases  this  connection  is  also  wanting:  episodically 
the  patient  is  entirely  a  different  personality.  Owing  to  the  fact  that 
no  rays  of  consciousness  pass  from  the  period  of  healthy  mental  life 
into  the  period  of  disease,  and  also  owing  to  the  fact  that  during  the 
insane  period  no  traces  of  memory  are  left  behind,  the  patient  lives  a 
completely  double  existence,  and  presents  two  sharply  differentiated 
personalities  in  time  (double  personality,  alternating  consciousness, 
double  mental  life).  Such  conditions  are,  for  the  most  part,  observed 
in  females  in  connection  with  the  development  of  puberty  and  as  one 
of  the  symptoms  of  an  hysteric  neurosis.  They  are  very  closely  related 
to  spontaneous  somnambulism. 

Consciousness  of  the  disease  also  depends  upon  the  degree  of  dis- 
turbance of  consciousness.  The  feeling  of  being  mentally  diseased  is 
more  frequently  present  than  is  usually  supposed.  Not  infrequently 
there  is  an  anxious  feeling  of  threatened  loss  of  mind  long  before  the 
oncoming  of  actual  disease,  especially  in  individuals  that  are  heredi- 
tarily predisposed. 

In  the  initial  stages  of  melancholia  this  feeling  is  usually  well 
marked,  and  not  infrequently  this  is  the  reason  why  such  lucid  patients 
often  request  to  be  admitted  to  an  asylum.  In  mania,  also,  even  at  its 
height,  the  patient  is  frequently  well  enough  aware  of  his  trouble,  and 
he  excuses  his  perverse  and  impulsive  conduct  by  saying  that  he  is  a 
fool,  and  therefore  everything  should  be  allowed  him. 

In  the  later  stages  of  insanity,  where  systematic  delusion  or  mental 
decay  has  developed,  the  patient  is  absolutely  without  insight  into  his 
abnormal  condition,  even  when  he  is  able  to  recognize  correctly  the 
insane  condition  of  his  companions;  and  thus  it  happens  that  such 
patients  are  constantly  complaining  and  demanding  that  an  end  be 
made  to  their  unjust  detention.  In  states  of  convalescence  insight 
into  the  disease-state  is  one  of  the  first  symptoms  of  returning  health. 

As  special  elementary  forms  of  disturbance  of  consciousness  in 
the  insane,  aside  from  forms  of  somnolence,  stupor,  coma,  etc.,  de- 
scribed m  general  cerebral  pathology,  there  are  still  to  be  men- 
tioned : — 

1.  States  of  psijchic  cloudiness.  In  these  conditions  ideas  do  not 
reach  complete  clearness  in  consciousness;  consciousness  of  time  and 
space,  as  well  as  that  of  personality,  is  decidedly  clouded;  appercep- 
tion of  the  external  world  is  weak  and  fragmentary,  and  takes  place  as 


ELEMENTARY  ANOMALIES  OF  THE  CEEEBRAL  FUNCTIONS.       99 

through  a  veil.  Memory  of  the  events  of  this  state  is  only  summary. 
Such  cloudy  states  of  consciousness  occur  in  epileptics  between  at- 
tacks, and  after  them,  but  also  as  temporary  states  without  any  relation 
to  attacks ;  finally,  in  the  course  of  chronic  alcoholism,  dementia  para- 
lytica and  dementia  senilis. 

2.  Dreamy  states  of  loalcing  life.  In  these  conditions  conscious- 
ness is  disturbed  even  to  the  extent  of  loss  of  self -consciousness  (uncon- 
sciousness in  the  forensic  sense)  ;  consciousness  of  the  external  world 
and  of  the  personality  is  extinguished,  or  at  least  reduced  to  a  mini- 
mum of  clearness.  Sensory  stimuli  do  not  penetrate  the  sphere  of 
self -consciousness ;  sensations  are  not  elaborated  clearly  to  conscious 
perceptions.  The  condition  resembles  that  of  one  in  a  dream,  only 
with  the  difference  that  the  psychomotor  sphere  is  not  inhibited;  so 
that  the  ideas  (deliria)  which  arise  as  a  result  of  inner  excitation  and 
the  hallucinations  are  expressed  in  motor  acts,  and  may  become  the 
motive  of  dreamy  action,  of  which,  however,  the  actor  is  as  uncon- 
scious as  he  is  incapable  of  recalling  them  afterward. 

Here  also  belong  certain  states  of  inanition  and  febrile  delirium, 
acute  states  of  intoxication,  forms  of  epileptic  disturbance  of  con- 
sciousness, pathologic  afl'ects,  and  somnambulism. 

3.  Stupor.  In  this  condition  all  the  psychic  functions  are  inhib- 
ited without,  however,  being  entirely  extinguished.  Consciousness  is 
clouded  in  so  far  as  the  ideas  do  not  attain  the  clearness  of  normal  life; 
apperception  is  cloudy,  retarded,  the  flow  of  ideas  is  obstructed,  and 
associations  are  slow.  But  the  inhibition  in  the  psychomotor  sphere 
is  pronounced.  The  patient  is  devoid  of  all  spontaneity;  stands  for 
hours  at  a  time  in  one  spot,  and  the  mien  is  expressive  of  indifference 
or  of  stupid  astonishment.  Voluntary  movements  are  but  seldom 
made,  and  then  with  evident  difi&culty  and  great  slowness. 

Along  with  the  psychic  inhibition  and  the  interference  with  the 
reflexes  there  is,  as  a  rule,  inhibition  of  spinal  reflex  excitabilit}',  and 
also  cutaneous  anesthesia  and  analgesia.  Innervation  of  the  vegetative 
organs  is  also  decreased ;  respiration  is  superficial  and  slow ;  the  heart- 
sounds  are  weak ;  the  pulse  is  poorly  developed,  small,  and  slow ;  peri- 
stalsis is  lessened  (obstipation)  ;  the  circulation  is  weak  (edema  of  the 
feet)  ;  temporary  cataleptic  states  may  occur. 

Such  stuporous  states  occur  as  postepileptic  and  postmaniacal 
phenomena;  as  episodes  in  dementia  paralytica  and  paranoia,  alter- 
nating with  maniacal  states  (vide  "Circular  Insanit}^,^^  "Special 
Pathology")  ;  primarily  and  independently  they  occur  after  violent 
fright,  great  loss  of  blood,  poisoning  with  carbonic  oxide  gas,  and 
strangulation;     as    accompanying    symptoms    of    melancholic    states 


100         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(melancholia  stupida)  ;  as  expression  of  brain  exliaustimi  after  severe 
acute  diseases  (tj'phoid) ;  also  after  sexual  and  especial ly  onanistic 
excesses. 

It  seems  possible  that  the  common  basis  of  ihese  conditions  is 
anemia  of  the- brain,  as  a  result  of  edema  (strangidation),  vasomotor 
spasm  (fright,  etc.),  and  inanition  (typhoid,  etc.). 

Jf.  Ecstasy.  In  this  condition  consciousness  is  dreamy  and  ab- 
sorbed in  inner  events.  It  is  narrowed  to  a  fixed  circle  of  ideas  of 
spontaneous  origin,  which  is  associated  with  a  lively  afTective  state 
of  feeling,  and  has  a  lively  hallucinatory  coloring.  In  this  state  of 
inner  concentration  the  registry  of  impressions  from  the  outer  Avorld 
and  from  the  body  at  large  is  suspended,  or  limited  to  that  which  is 
immediately  related  to  the  dreamy  ideas. 

The  psychomotor  sphere  is  limited  to  a  single  direction  of 
thought;  the  individual  resembles  a  statue,  and  the  muscles  may  tem- 
porarily present  the  condition  of  flexihilitas  cerea. 

Ecstasy  occurs  mainly  in  women,  especially  upon  an  hj'steric 
foundation.  Anemic  states,  uterine  diseases,  functional  anomalies  of 
the  sexual  organs  on  the  physical  side,  and  religious  exaltation  on  the 
mental  side  are  predisposing  conditions. 

Not  infrequently  it  precedes  hysteric  convulsions,  or  follows  them. 
Self-consciousness  is  entirely  wanting  or  is  ver}''  much  clouded,  and 
thus  memory  of  the  events  of  the  attack  is  entirely  wanting  or  is 
limited  to  a  few  reminiscences  of  the  hallucinatory  delirium. 


CHAPTER  VL 
Disturbances  of  Speech  in  Insanity. 

Language,  as  the  means  of  expressing  thought  and  as  an  imme- 
diate function  of  the  cerebral  cortex,  presents  important  sources  of 
knowledge  for  the  alienist,  not  only  in  revealing  the  content  of  thought, 
but  also  in  the  manner  in  which  it  reveals  it. 

Language  consists  of  gesture,  speech,  and  writing. 

The  conditions  necessary  for  intercourse  by  means  of  language,  according 
to  Exner,  are  as  follows:  1.  Hearing  the  words  of  others  (if  deafness  does  not 
exist).  2.  LTnderstanding  of  woi'ds  (when  word-deafness  does  not  exist).  3. 
Development  of  associated  thought  which  formulates  the  answer  (possible  so 
long  as  the  formation  of  thought  is  not  disturbed  by  mental  disease).  4. 
Clothing  the  ideas  which  constitute  the  answer  in  words  (possible,  so  long  as 
there  is  no  amnesic  aphasia).  5.  Transformation  of  the  word-ideas  into  the 
corresponding  motor  ideas  (possible  so  long  as  ataxic  aphasia  does  not  exist). 


ELEMENTARY  ANOMALIES  OP  THE  CEREBRAL  FUNCTIONS.    ]  01 

6.  Transference  of  innervation-impulses  in  proper  strength  and  co-ordination 
to  the  muscles  of  speech  (possible  so  long  as  there  is  no  disease  in  the  cereVjral 
motor  tracts  or  the  medulla). 

In  states  of  low  mental  development  (congenital  and  acquired), 
language  may  be  limited  to  gestures  or  sounds  (idiots  and  dements)  as 
interpreting  affects  or  feelings. 

At  a  higher  stage  of  development  the  language  of  certain  imbeciles 
stands  on  a  higher  plane.  It  is  analogous  to  that  of, young  children 
and  parrots  who  are  able  to  repeat  what  is  said  in  their  hearing, — 
the  whole  phrase  or  at  least  the  last  word  (echo-speech).  At  a  higher 
stage  of  development  there  is  a  word-speech  for  the  designation  of  the 
most  common  and  important  necessities,  which  gradually  also  shows 
the  beginning  of  grammatic  form  and  of  the  formation  of  sentences, 
and  becomes  richer  and  richer,  until  it  reaches  the  height  of  compre- 
hensive significance.     The  highest  expression  of  language  is  writing. 

In  accordance  with  this  idea,  language,  both  in  content  and  form, 
is  one  of  the  most  delicate  indications  of  the  content  of  consciousness 
and  the  capabilities  of  the  psychic  mechanism. 

Without  reference  to  purely  articulatory  disturbances  of  speech 
which  find  their  description  in  special  pathology  (idiocy,  paralysis, 
etc.),  here  we  have  to  deal  only  with  dysphasia  and  dysphrasia  (Kuss- 
maul), which  are  brought  about  by  disturbances  of  the  cerebral  cortex. 

1.  Dyspheasias  are  the  most  frequent.  They  may  consist  of 
anomalies  of  tempo,  of  form  of  speech,  of  syntactic  diction,  and  of  the 
content  of  speech. 

(a)  Increase  in  the  rapidity  of  speech  as  an  expression  of  facili- 
tated thought  and  expression  occurs  in  states  of  psychic  exaltation, 
especially  in  mania  (logorrhea,  polyphrasia). 

In  this  condition  at  the  same  time  diction  is  facilitated,  more 
flowing,  and  even  brilliant  (maniacal  exaltation),  until,  with  the 
ever-increasing  flow  of  thought  (flight  of  ideas)  and  the  omission  of 
connecting  members,  only  disconnected  words  and  even  sounds  cause 
reflex  activity  in  the  speech  mechanism.  Under  such  circumstances 
incoherence  necessarily  results  (height  of  mania),  and  there  is  an  end 
of  grammatic  association  of  words  in  sentences.  Confusion  of  speech 
may  also  result  from  mere  disturbance  of  association  (confusion, 
affect)  ;  from  a  superficial  similarity  of  the  sounds  of  words  associated 
in  a  train  of  thought  (maniacal  and  paranoiac)  ;  from  states  of  mental 
weakness  in  which  words  are,  as  it  were,  no  longer  anything  more  than 
mere  hulls  and  are  incorrectly  employed  (certain  paranoiacs)  ;  and 
also  from  paraphasia.  Such  conditions  are  immediately  difl^erentiated 
from  the  incoherence  of  the  maniacal  by  the  slowness  of  speech-. 


103         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Slow  and  even  stuttering  speech  is  observed  in  many  melan- 
cholies and  dements.  In  the  former  it  is  the  result  of  the  slow  and 
inhibited  thought,  or  of  the  disturbing  influence  of  hallucinations  and 
emotional  states;  in  the  latter,  it  is  due  to  the  incapability  of  forming 
a  thought,  as  a  result  of  mental  weakness.  Both  disturbances  may 
lead  to  complete  dumbness  (mutism),  as  obser^■ed  in  melancholia  due 
to  increase  of  inhibition,  and  want  of  reflex  in  the  organs  of  speech 
(melancholia  with  stupor);  in  dementia  as  a  result  of  lack  of  speech 
ideas  (idiocy,  deaf-mutism);  in  apathetic  acquired  dementia  and 
stupor,  where  word-images  have  been  lost. 

However,  mutism  is  often  the  result  of  delusions  and  imperative 
hallucinations  (religious  paranoia)  ;  sometimes  it  also  occurs  in  hys- 
teric insanity,  as  a  result  of  the  globus-sensation. 

(h)  Interesting  anomalies  in  the  manner  of  speech  are  presented 
by  the  pathetic  speech  of  the  ecstatic  and  of  the  exalted  paranoiac 
(which  are  due  to  the  superabundance  of  feeling  and  emotional  excite- 
ment) dependent  upon  an  increased  consciousness  of  self;  by  the 
trivial^  silly  diction  of  certain  paranoiacs  and  hebephreniacs,  who  use 
diminutives;  and  by  the  rhymed  speech  of  the  maniacal.  Here 
should  also  be  mentioned  what  Kahlbaum  first  described  as  "verbigera- 
tion," in  which  the  patient  pronounces  words  and  sentences  which 
have  the  form  of  speech,  but  which  are  absolutely  without  meaning 
and  disconnected.  Kahlbaum  differentiates  this  verbigeration  from 
the  incoherent  talk  of  the  confused  and  demented,  by  means  of  the 
trivial  content  of  the  conversation  of  the  latter  patients,  and  from 
the  speech  of  the  maniacal  by  the  progressive  content  of  the  latter :  i.e.^ 
the  flight  of  ideas,  which  does  not  come  back  to  the  same  connection 
of  words,  whereas  the  patient  affected  with  verbigeration  repeats  the 
same  words  and  sentences  ad  infinitum. 

Frequent  repetition  of  the  same  words  may  occur  also  as  a  result 
of  psychic  motives.  Thus,  for  instance,  one  suffering  with  religious 
paranoia,  out  of  special  respect  for  the  number  "  3,"  may  repeat  every 
word,  spoken  or  written,  three  times.  A  patient  of  Morel  repeated 
words  frequently,  owing  to  the  hypochondriac  delusion  that  she  was 
losing  her  speech, 

(c)  Defects  of  syntax  in  diction  occur  in  paranoiacs  and  dements. 
They  consist  in  imusual  association  of  words,  in  the  substitution  of 
nouns  for  verbs,  or  in  the  neglect  of  endings  and  conjugation;  as  a 
result  of  which  the  patient  speaks  as  a  little  child,  using  indefinite 
nouns  or  infinitives  or  perhaps  past  participles;  instead  of  pronouns, 
using  nouns  {e.g.,  "Toni  Blumen  genommen,  Wärterin  gekommen, 
Toni  g.ehaut " — Kussmaul). 


ELEMENTARY  ANOMALIES  OP  THE  CEREBRAL  FUNCTIONS.    103 

(d)  Finally  of  the  greatest  interest  among  the  dysphrasias,  along 
with  poverty  of  speech  in  content  and  diction,  is  the  formation  of  new 
words.  This  occurs  mainly  in  paranoiacs,  and  very  rarely  in  the 
maniacal. 

This  onomatopoiesis  is,  for  the  most  part,  of  hallucinatory  origin, 
or  arises  out  of  the  impulse  to  form  a  new  descriptive  word  for  a 
new  abnormal  feeling  or  thought,  or  for  what  to  the  patient  is  the 
strange  process  of  hallucination;  because  in  ordinary  language  the 
patient  is  able  to  find  no  word  to  designate  it.  These  newly  formed 
words  are  essentially  creations  of  the  unconscious  brain  mechanism, 
like  those  which  in  physiologic  states,  both  waking  and  dreaming,  may 
be  presented  to  consciousness  in  the  planless  association  of  senseless 
sounds. 

3.  Dysphasias. — According  to  KussmauFs  excellent  classifica- 
tion, the  aphasias  occurring  in  brain  diseases  with  predominating 
mental  symptoms  (traumatic,  apoplectic,  and  paralytic  insanity),  and 
also  not  infrequently  in  epileptics,  belong  here.  For  the  most  part, 
the  aphasia  is  amnesic,  less  frequently  ataxic.  At  the  same  time  there 
is  frequently  alexia,  agraphia,  and  also  paralexia  and  paragraphia, 
word-deafness,  and  word-blindness  (dementia  paralytica).  The  de- 
mentia that  is  usually  coexistent  makes  it  difficult  to  ascertain  the  pres- 
ence of  the  aphasic  symptom,  the  more  since  the  patient  himself  is 
unconscious  of  his  paralexia  and  paragraphia. 


CHAPTER  VII. 
Psychosensorial  Disturbances. 

Among  the  most  important  elementary  anomalies  in  insanity  are 
the  sense-deliria,  or  deceptions  of  the  senses :  i.e.,  errors  which  arise 
in  the  sphere  of  the  senses  and  as  a  result  of  sensory  impressions 
(Hagen), 

Since  Esquirol,  who  was  the  first  to  investigate  and  study  carefully 
these  symptoms,  it  is  usual  to  distinguish  two  phenomena:  (1)  hal- 
lucination; (2)  illusion.  The  difference  between  these  two  lies  in 
this:  that  in  hallucination  there  is  no  external  stimulus  as  a  source 
of  subjective  sensory  perception,  while  in  illusion  a  stimulus  coming 
from  without,  or  arising  spontaneously  in  the  peripheral  sensory 
apparatus,  on  its  way  to  the  organ  of  apperception  is  distorted,  and 
thus  reaches  consciousness  in  distorted  form. 


104         GENERAL  PATHOLOGY  AND  THERArY  OF  INSANITY. 

1.  Hallucination, 

The  person  troubled  with  haUucinations  sees,  hears,  smells,  tastes, 
thinks,  and  feels  with  the  complete  certainty  of  an  objectively  founded 
sensory  perception  which  has  no  actual  objective  foundation. 

The  process  is  decidedly  abnormal.  Since  disease  is  nothing  else 
than  function  under  abnormal  conditions,  scientific  investigation  of 
this  phenomenon  must  keep  in  mind  function  under  normal  conditions, 
and  ascertain  the  deviations  from  the  normal  conditions. 

The  normal  process  of  perception  is  made  up  of  three  acts: — 

1.  The  reception  of  a  physical  stimulus  from  the  external  world  by  the 
end-organ  of  a  sense-apparatus  (retina,  organ  of  Corti,  tactile  corpuscle),  and 
the  conveyance  of  this  plienomenon  of  movement  by  the  centripetal  path  of 
the  sensory  nerves  involved. 

2.  The  ti'ansformatit)n  of  this  mode  of  motion  in  the  endings  of  the 
sensory  nerves  in  the  brain  (organ  of  perception,  center  of  sensation,  sub- 
cortical center)  into  an  elementary  psychic  phenomenon  (sensation). 

3.  The  conveyance  of  tlie  movement  that  has  been  modified  in  the  sub- 
cortical center  bj'  paths  leading  to  the  cerebral  cortex,  and  thus  to  the  central 
end-station  of  the  sensory  path  (sensorial  center,  apperceptional  center, 
ideational  center). 

If  this  latter  end-station  is  in  a  certain  state  of  functional  excitement, 
which  is  called  attention,  and  if  it  contains  residua  of  former  excitation  (sen- 
sory memory-pictures),  then  the  excitation  reaching  the  cortical  end-station 
calls  up  these  residua.  As  a  result  of  the  combination  of  a  memory-picture 
then  awakened  with  the  centripetal  process,  a  perception  takes  place:  i.e., 
interpretation  of  a  sensory  impression  in  the  sense  of  a  memory-picture  of  an 
earlier  impression,  which,  according  to  the  law  of  eccentric  projection,  or  refer- 
ence to  the  place  of  origin  in  the  external  world,  is  projected  into  space.  Tlie 
whole  of  this  complicated  process  of  sensorj'  perception  is  for  us  unconscious, 
and  only  the  complete  result  of  it,  the  idea,  the  sense-perception,  enters 
consciousness. 

The  process  of  perception  takes  place,  in  accordance  with  the  readiness 
and  the  functional  capability  of  the  center  of  apperception,  with  lightning- 
like rapidity,  intuitively,  or  slowly  and  with  difficulty. 

If  the  memory-picture  that  has  been  called  up  or  combined  corresponds 
with  the  centripetal  excitation, — i.e.,  resembles  that  which  caused  the  original 
memory-picture,— then  the  perception  appears  as  individually  correct  and 
adequate.  In  the  case  of  lack  of  resemblance  the  subject  of  the  phenomenon 
is  deceived  with  reference  to  his  perception   (psychic  illusion). 

Owing  to  the  imminent  capability  of  memory  in  the  cortical  sensory  cen- 
ters, the  memory-picture  of  a  previous  perception  may  be  called  up  into 
consciousness  passively  or  actively. 

Passive  reawakening  may  occur  organically  as  a  result  of  spontaneous  or 
reflex  excitation;  functionally,  it  may  be  the  result  of  a  new  centripetal  ex- 
citation in  the  sensory  path,  or  of  association  of  ideas. 

Active  reawakening  is  possible  as  a  result  of  voluntary  calling  up  of 
memory-pictures. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FCNCTFOXS.     i  or, 

If  tlie  power  of  memory  is  intact,  then  the  intogiuty  of  active  reproduc- 
tion is  unchanged.  Reproduction  in  changed  form  as  a  result  of  union  with 
other  memory-pictures  is  not  possible  in  spontaneous  reproduction. 

A  fundamental  difference  between  memory  and  perception  (imaginative 
and  sensory  thought — Sully)  lies  in  the  fact  that  the  former,  under  ordinary 
circumstances,  produces  only  an  ideal,  and  not  a  sensory,  memory-picture.  It 
is  probably  due  to  this  that  consciousness  is  able  to  distinguish  easily  at  all 
times  memory-pictures  and  actual  perceptions.  The  reason  for  this  is  only  to 
be  found  in  the  fact  that  in  the  occurrence  of  the  image  of  perception  the 
whole  sensory  apparatus  is  involved,  while  in  the  reproduction  of  a  memory- 
picture  the  sensory  apparatus  is  not  involved,  or  at  least  with  less  intensity 
than  in  the  occurrence  of  the  perception-image.  When  a  memory-picture  at- 
tains the  intensity  of  a  sensory  perception  (hallucination)  the  presumption 
arises  that  under  abnormal  conditions  the  sensory  apparatus  is  thrown  into  a 
state  of  excitement  outward  from  the  center  almost  as  intense  as  that  which 
occurs  when  a  real  sensory  perception,  based  upon  physical  stimuli  from  the 
outer  world,  is  induced. 

Owing  to  the  deficiency  of  our  knowledge  of  the  functions  of  the  various 
portions  of  the  sensory  apparatus,  investigation  of  them  is  extremely  difficult. 

That  the  degree  of  intensity  of  memory-pictures  is  not  insignificant  is 
shown  by  the  fact  that  the  exciting  causes  for  the  occurrence  of  hallucina- 
tions may  be  said  to  consist  essentially  in  the  fact  that  they  induce  an  intense 
excitation  and  concentration  of  thought.  Functionally  this  is  brought  about 
by  emotional  states  (fear,  fright,  enthusiasm) ;  also  by  intensification  of 
attention  (expectation,  lively  interest  in  an  object) ;  and  by  want  of  external 
stimuli  (darkness,  isolation,  etc.).  The  conditions  obtaining  in  solitary  con- 
finement are  especially  favorable,  where  the  emotions,  pangs  of  conscience,  and 
longing  for  freedom  are  present  and  call  up  lively  memory-pictures;  and 
where,  besides,  owing  to  want  of  external  sensory  stimuli,  there  is  occasion 
for  pre-occupation  with  imagination. 

Hallucinations  are  actually  not  infrequent  in  solitary  confinement.  Tlie 
organic  origin  of  them  is  facilitated  by  lively  memory-pictures,  in  so  far  as 
often,  in  diseases  of  the  cerebral  cortex,  they  are  called  up,  not  by  the  dynamic 
functional  psychologic  way  of  association,  but  in  the  organic  physiologic  Avay. 

Among  the  inner  organic  irritative  processes  affecting  the  sensory  areas 
of  the  cortex  are  disturbances  of  nutrition,  which  are  easily  induced  by  con- 
ditions that  give  rise  to  insanity;  such  as  febrile  diseases,  states  of  inanition, 
and  intoxication. 

States  of  inanition  (anemia)  especially  favor  the  occurrence  of  hallucina- 
tions (shipwreck,  privation  in  deserts,  exhaiistion  due  to  acute  diseases  or  the 
loss  of  blood,  in  fasting  ascetics,  etc.). 

But  within  physiologic  limits  there  are  great  variations  in  the  intensity 
of  memory-pictures.  Thus,  it  is  well  known  that  in  youth  the  imagination  is 
much  more  active  than  in  old  age;  in  the  aged,  especially,  visual  memory- 
■pictures  are  very  poorly  reproduced. 

There  are  individuals  of  bad  memory,  even  of  partially  bad  memory,  as  a 
result  of  original  constitution,  in  contrast  with  others  who  reproduce  sensory 
images  with  extraordinary  clearness.  The  latter  endowment  is  characteristic 
of  artists  simply  as  reproduction  and  also  as  fantastic  transformation.     It  is 


106         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

probable  that  the  woiuleiful  art  of  many  celebrated  actors,  and  the  wonderful 
phistic  descriptions  of  Goethe,  Ossian,  and  Homer,  depend  on  this.  Probably 
the  fineness  of  instrumentation  ajid  tone-color  of  the  compositions  of 
composers  depends  upon  an  especially  fine  and  lively  reproduction  in  acoustic 
memory.  That  such  individuals  of  extraordinary  sensory  endowment  are 
more  easily  hallucinated  than  those  that  are  devoid  of  imagination  and  richer 
in  abstract  ideas  will  be  admitted  at  once;  indeed,  their  memory-pictures  are 
sometimes  so  intensified  voluntarily  as  to  resemble  plastic  hallucinations 
(Goethe).  These  plastic  thoughts  (psychic  hallucinations — Baillarger;  pseudo- 
hallucinations — Kahlbaum),  these  lively  inner  voices,  present  easy  transitions 
to  hallucinations;  and,  on  the  other  hand,  observation  of  the  insane  shows 
that  their  hallucinations  have  not  always,  and  only  infrequently  from  the 
beginning,  the  intensity  of  actual  sensory  perceptions. 

It  remains  questionable  whether  the  most  intense  reproduction  of  a 
sensory  memory-picture  or  powerful  excitation  of  the  center  in  the  cortex 
suffices  to  lend  to  the  memory-picture  the  sensory  intensity  of  an  image  of 
perception:    i.e.,  to  change  it  into  an  hallucination. 

All  our  present  knowledge  of  cortical  physiology  justifies  the  assumption 
that  the  sensory  centers  of  the  cortex  are  only  places  for  the  act  of  perception 
and  the  retention  of  corresponding  memory-pictures.  The  memory-picture 
which  has  become  intensified  to  plastic  expression  (hallucination)  cannot  be 
reproduced  at  any  other  point  of  the  sensory  apparatus.  In  the  subcortical 
centers,  as  a  result  of  spontaneous  inner  excitation,  elementary  sensory  im- 
pressions (lights,  colors,  tones)  may  be  reproduced,  and  may  reach  the 
intensity  of  actual  sensations,  but  never  forms,  words,  and  complicated  mem- 
orj'-pictures. 

In  order  that  a  memory-picture  may  become  an  hallucination 
it  is  necessary  that  there  be  a  functional  simultaneous  excitement  of 
the  whole  centro-peripheral  sensory  path,  analogous  to  that  which 
takes  place  in  the  process  of  sensory  perception,  thus  increasing  its 
intensity. 

The  changed  conditions  are  such  that  it  is  not  an  external  phys- 
ical stimulus,  but  an  inner  psychologic  process  that  excites  the 
sense-apparatus  to  activity.  Sensory  perception  is  a  centripetal 
process;  hallucination  is  a  centrifugal  process.  Both  have  this  in 
common:  that,  in  accordance  with  the  law  of  eccentric  projection  of 
perception,  the  cause  of  excitation  in  the  periphery  of  the  sensory 
path  is  projected  into  external  space. 

Thus  the  deception  becomes  complete,  and  can  be  recognized  as 
such  by  the  consciousness  of  the  hallucinated  individual  only  indirectly. 
In  what  this  capability  of  the  sensory  path  to  react  to  a  purely  psychic 
ideational  stimulus  consists  can  only  be  the  subject  of  conjecture. 

We  might  think  of  this  condition  of  increased  impressionability 
as  an  hyperesthesia. 

At  any  rate,  the  phenomenon  is  purely  functional.  In  general, 
hallucination  is  more  frequent  in  the  so-called  purely  functional  brain 


ELEMENTAPvY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.     107 

diseases^  in  wiiicli  also  increased  Iiiiiclioual  cxcitaldlity  is  Ki)iiiillaiie- 
ously  observed  in  other  functional  domains.  Thus  is  explained  the 
frequency  of  liallueinations  in  functional  psychoses,  hysteria,  epilepsy, 
chorea,  etc.  Such  a  functional  cliange  of  the  sensory  path  as  tlie 
fundamental  condition  for  the  occurrence  of  hallucination  is  a  pos- 
tulate of  experience;  for  other,wise  hallucination  would  he  an  everyday 
phenomenon,  since  the  conditions  for  the  increase  of  intensity  of  a 
memory-picture  very  readily  occur  (emotion,  attention,  concentration, 
voluntary  intensification  of  imagination).  If  these  conditions  lead 
actually  to  hallucinations,  it  allows  the  presumption  of  an  abnormal 
excitability  of  the  centro-peripheral  sense-apparatus.  That  hallucina- 
tions may  arise  merely  in  the  sensory  centers  of  the  cortex  is  shown  by 
the  following  facts  of  experience : — 

1.  The  disappearance  of  hallucinatory  phenomena  when  the  sen- 
sory center  in  the  cerebral  cortex  is  destroyed,  with  consequent  loss  of 
the  memory-j)ictures  (organic  cortical  disease,  apathetic  dementia). 

2.  The  possibility  of  hallucination  when  the  external  sense-organs 
are  completely  destroyed. 

3.  The  limitation  of  stimulation  of  the  peripheral  sense-appa- 
ratus, with  its  subcortical  center,  to  the  production  of  elementary 
subjective  sensations  (lights,  noises),  and  the  exclusion  of  images 
and  words. 

4.  The  content  of  the  hallucination  is  largely  in  harmony  with  the 
content  of  thought.  It  represents  visual  ideas-  that  have  become  plas- 
tic; auditory  ideas  that  have  the  value  of  sounds.  It  is  only  in  this 
way  that  we  can  understand  how  hallucinations  of  like  content  some- 
times become  epidemic  among  persons  who  are  pre-occupied  with  the 
same  circle  of  ideas,  and  thus  are  placed  in  the  same  state  of  emotional 
excitement. 

However,  the  content  of  thought  and  the  content  of  an  hallucina- 
tion are  not  always  congruent.  In  order  to  understand  this  fact  it  is 
necessary  to  ascertain  in  what  ways  memory-pictures  that  become  hallu- 
cinations may  be  awakened.  The  relations  are  quite  analogous  to  those 
which  exist  in  the  origin  of  a  purely  ideational  image — like  a  delusion 
(vide  supra).  The  awakening  of  the  memory-picture  which  becomes 
an  hallucination  may  occur  spontaneouslj^  through  a  physiologic  or- 
ganic path,  or  as  a  resiüt  of  association.  In  the  first  case  it  is  not  at 
all  necessary  that  the  memory-picture  be  a  conscious  one.  Ai  the 
moment  of  its  awakening  it  may  become  active ;  so  that  the  individual 
is  conscious  of  it  only  when  it  appears  as  an  hallucination. 

The  source  of  excitement  may  be  direct,  such  as  an  irritation  in 
the  sensory  cortical  center.     It  is  also  possible  that  this  excitement  is 


108  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tlie  rosult  of  o.xcitatiou  in  the  peripheral  sensory  path,  or  the  result  of 
excitation  in  some  visceral  sensory  path,  that  has  been  carried  to  the 
center. 

The  memory-picture  that  has  arisen  as  a  result  of  association, 
and  become  ah  hallucination,  as  a  rule  arises  consciously,  and  thrusts 
itself  into  the  process  of  concrete  conscious  thought.  However,  it  is 
not  necessary  that  it  appear  in  the  original  and  identical  form;  more 
frequently  it  appears  in  a  form  that  is  fantastically  changed.  It  may 
be  awakened  by  an  associative  reproduced  idea,  by  a  sensory  perception, 
or  finally  by  another  hallucination.  In  the  latter  case  it  is  customary 
to  call  the  secondary  hallucination  a  reflex  hallucination  (Kahlbaum). 
The  content  of  an  hallucination  may  be  stable  (a  constant  associative 
memory-picture  as  the  result  of  concentration,  emotion,  or  constant 
excitation  following  an  organic  or  peripheral  stimulus  of  a  certain 
quality),  or  the  content  may  be  kaleidoscopic. 

In  some  infrequent  cases  hallucinations  are  limited  to  one  eye  or 
one  ear.  In  such  cases  we  are  dealing  with  illusions,  or  at  least  with 
stimuli  that  are  conducted  to  the  sensory  center  from  the  given  sensory 
path  involved.  However,  an  organic  one-sided  stimulus  in  the  cortical 
center  is  possible. 

Whenever  images  that  have  arisen  in  the  psychologic  way  of  asso- 
ciation of  ideas  continue  in  consciousness  and  are  capable  of  exciting 
the  sensory  center  to  the  extent  of  inducing  hallucinations,  it  must  be 
concluded  that  there  exists  a  high  degree  of  hyperesthesia  of  the  centro- 
peripheral  sensory  apparatus. 

Examples  of  this  are  presented  by  patients  who  think  that  they 
lioar  spoken  what  they  read  or  think,  or  who  complain  that  their 
tlionghts  are  spied  out  and  read  by  others. 

Many  of  these  phenomena  should  be  called  pseudo-hallucinations ; 
this  is  especially  true  of  those  cases  in  which  the  patients  are  conscious 
of  this  inner  subjective  origin  of  the  hallucinations,  and  speak  of  them 
as  thinking  aloud,  like  Leuret's  patient  ("It  is  something  that  works 
inside  of  my  head^^). 

The  nosologic  significance  of  an  hallucination  is  that  of  an  ele- 
mentary disturbance  of  the  psychosensorial  functions.  It  always 
indicates  an  abnormal  condition  of  the  central  nervous  system.  It 
occurs  most  frequently  in  insanitj'-,  but  it  is  not,  in  itself,  a  criterion 
of  mental  disease. 

The  psychologic  significance  of  an  hallucination  is  that  of  an 
actual  sensory  perception.  To  the  hallucinated  person  it  does  not  seem 
merely  so,  but  he  sees,  hears,  tastes,  and  feels  with  an  intensity  equal 
to  that  of  a  sensory  impression  induced  by  an  actual  object.     It  is  of 


ELEMENTARY  ANOMALIES  OF  'J'llE  CEJiEBKAL  FIJNOIONS.     109 

decisive  iinportaiU'C  what  l)C('()mos  of  tlic  subjective  sojisoi'y  j)<'r(;cptj()ii, 
of  the  elementary  clisliirljancc:  whctlier  it  he  rocogrii/ed  as  ai)  Jialhi- 
cjnation  by  consciousness  or,  not  being  recogiiizec]  as  such,  Irad  to  u 
falsification  of  consciousness. 

The  result  is  dependent  upon  tlie  condition  of  consciousness  in 
general  and  the  integrity  of  the  other  senses.  Correction  is  the  rule  in 
those  that  are  not  insane.  Intact  clearness  and  attention,  and  tJie 
perfect  activity  of  the  other  senses  and  their  healthful  testimony, 
almost  necessarily  lead  to  a  correction  of  the  sensory  image.  It  is 
psychologically  interesting  to  ohserve  the  disturbing  influence  of  a 
seemingly  supernatural  phenomenon,  even  on  those  mentally  sound 
and  familiar  with  it. 

.  As  a  rule,  in  the  insane  the  hallucination  is  mistaken  for  an 
objective  sensory  impression,  since  self -consciousness  is  here  dis- 
turbed, emotions  disturb  the  clearness  and  quietness  of  reflection,  and 
frequently  hallucinations  of  other  senses  coexist;  so  that  a  subjective 
sensory  perception  of  some  other  sense  comes  to  its  support,  while,  at 
the  same  time,  the  paths  for  correcting  and  controlling  sensory  per- 
ceptions are  pre-occupied. 

It  also  happens  that  even  insane  persons  correct  their  hallucina- 
tions. This  occurs  principally  when  the  hallucinations  affect  but  one 
sense  and  are  of  infrequent  occurrence ;  when  they  are  unaccompanied 
by  emotional  states,  when  the  individual  belongs  to  the  educated  class ; 
and  when  the  hallucination  consists  of  the  momentary  plastic  expres- 
sion of  a  corresponding  thought  or  of  words  that  are  read. 

However,  the  thoughts  which  provoke  hallucinations  seem  to  be, 
for  the  most  part,  produced  by  spontaneous  non-associative  brain  exci- 
tation; or  at  least  they  are  not  recognized  in  consciousness  by  the 
patient  before  they  take  the  form  of  an  hallucination.  Thus  it  hap- 
pens that  the  content  of  an  hallucination  does  not  correspond  with 
conscious  thought,  is  looked  upon  as  something  foreign,  and  its  cause 
is  placed  in  the  external  world. 

This  calls  up  a  not  unimportant  practical  question:  namely,  whether 
hallucinations  that  are  not  recognized  as  such  are  signs  of  insanity.  There 
are  authors,  especially  among  the  French,  who  have  not  hesitated  to  answer 
this  question  in  the  af3firmative,  but  without  jiistilication;  for,  in  the  first 
place,  an  hallucination,  even  when  it  is  regarded  as  an  actual  fact,  is  only  an 
elementary  phenomenon  that  reveals  nothing  concerning  the  general  state  of 
the  individual,  and  nothing  concerning  the  condition  of  the  brain ;  and,  in  the 
second  place,  experience  offers  us  examples  of  many  persons  who  have  believed 
in  the  reality  of  their  hallucinations,  but  who  could  not  be  regarded  as  insane 
(]\rohammed:  Napoleon;  Socrates,  who  conversed  with  his  demon;  Benvenuto 
Cellini,  who,  wliile  he  prayed  in  prison  that  God  might  let  him  see  the  light 


110         GENEPxAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

of  the  sun  once  more,  had  a  vision  ol  the  sun;  Pascal,  who  saw  an  abyss  be- 
fore him;    Joan  of  Arc;    Luther,  who  threw  his  inkwell  at  the  devil,  etc.)- 

The  explanation  of  this  is  not  difficult,  when  it  is  remembered  that  such 
hallucinated  persons,  controlled  by  the  delusions  and  superstition  of  their 
time,  or  by  the  tendency  to  the  belief  in  wonders  and  mysticism,  were  not 
disposed  to  correct  these  creations  of  their  imagination. 

But  nevertheless  we  must  hold  fast  to  the  fact  that  hallucinations  that 
are  held  to  be  true  are  manifestations  that  endanger  the  integrity  of  relations 
to  the  actual  external  world. 

Simple  as  it  seems  to  establish  the  hallucination  as  such,  it  may 
still  be  very  difficult  to  keep  from  confounding  it  with  other  abnormal 
]ihenomena  that  occur  in  insanity.  Without  doubt,  many  manifesta- 
tions are  held  to  be  hallucinations  that  are  not. 

Some  of  these  are : — 

(a)  Dreams  of  many  paranoiacs,  who,  in  their  fanc}^  are  like  the 
actor,  and  feel  themselves  to  be  in  the  role  or  in  the  situation  to  carry 
out  dialogues  without  seeing  or  even  hearing  an  actual  person 
(Hagen).  • 

(h)  The  reproduction  of  dream-pictures  and  their  transference 
into  the  waking  state  as  actual  events.  This  defect  of  discrimination 
is  observed  in  states  of  mental  weakness. 

(c)  The  confounding  of  an  idea  that  has  thus  arisen  with  the 
supposed  memory-picture  of  an  actual  perception.  Here  belong  those 
cases  in  which  the  patients  declare  that  some  one  has  said  this  or  that 
about  them,  insulted  them,  while,  in  fact,  they  only  imagine  this  for 
the  moment.  The  statements  of  such  patients  differ,  in  their  lack  of 
definiteness,  from  the  content  of  actual  hallucinations  (Hagen). 

Signs  that  with  much  certainty  point  to  the  existence  of  hallucina- 
tion are:  breathless  listening  for  sound  expected  from  a  certain 
direction;  a  stare  directed  to  a  certain  point;  stopping  the  ears  and 
covering  the  face. 

Many  patients,  without  being  asked,  will  tell  of  their  "'voices," 
and  designate  the  process  of  hallucination  with  a  peculiar  name. 

The  formation  of  new  words,  silence,  and  refusal  of  food  are  symp- 
toms that  are  very  frequently  induced  by  hallucination. 

It  remains  to  allude  briefly  to  the  social  and  historic  significance  of 
hallucinations. 

There  is  hardly  a  phenomenon  of  human  life  which,  throughout  the  ages, 
has  been  more  variously  judged  by  the  church,  philosophy,  and  natural  science. 
The  history  of  hallucinations  contains  a  part  of  the  history  of  the  civilization 
of  all  peoples  and  all  times,  and  is  a  mirror  of  religious  opinions. 

Hallucinations  have  caused  the  most  important  historic  events  (visions 
of  the  cross  of  Constantin  the  Great),  founded  religions  (Mohammed),  and  led 
to  the  most  horrible  errors  in  the  form  of  superstition,  ghosts,  and  persecution 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS,    m 

of  witches.  They  are  of  the  greatest  importance  as  giving  origin  to  folklore 
and  fables  (belief  in  fairies,  ghosts,  elfs,  devils,  etc.)  ;  and  it  is  not  accidental 
that  such  stories  have,  for  the  most  part,  arisen  among  the  peasants,  shep- 
herds, and  hunters:  i.e.,  in  men  whose  life,  in  most  immediate  contact  with 
Nature,  exercises  a  most  powerful  influence  upon  the  imagination. 

A  good  example  of  this  is  presented  by  the  "second  sight"  of  the  High- 
landers, consisting  in  the  belief  that  certain  nervous  persons  have  the  gift  of 
seeing  others  in  future  states,  as  upon  the  bier:  things  which  may,  of  covirse, 
incidentally  become  true. 

The  ominous  appearance  of  one's  own  form  is  of  the  same  nature 
(Goethe's  gray  vision  of  himself  as  he  rode  to  Drusenheim). 

Finally,  hallucinations  are  very  frequent  in  the  history  of  the  cloisters, 
wehere  nervous  disposition,  chastisement,  lack  of  sleep,  intense  concentration 
of  thought  on  a  few  ideas,  with  consequent  increase  of  imagination,  and,  per- 
haps, also  onanism,  tended  to  provoke  them. 

Hallucinations  have  a  most  powerful  effect  in  poetic  creations,  and 
therefore  poets,  either  conscious  of  the  ps3'cliic  significance  of  hallucina- 
tion or  instinctively,  when  they  wish  to  make  a  ]oowerful  impression, 
make  use  of  hallucination.  The  vision  of  Macbeth,  in  Shakespeare's 
drama,  when  Macbeth  finds  his  place  at  the  table  already  occupied  by 
the  ghost  of  the  murdered  Banquo,  is  most  impressive. 

An  excellent  example  of  the  use  of  hallucination  in  poetic  art  is 
offered  by  Goethe's  "Erl  King.'' 

2.  Illusion". 

Illusions  are  to  be  differentiated  from  hallucinations.  They  are 
sensory  impressions,  which,  on  the  way  to  the  organ  of  apperception, 
undergo  falsification,  and  consciousness  is  deceived  concerning  the 
source  of  the  sensory  phenomena. 

Their  occurrence  depends  upon  the  existence  of  the  peripheral 
sensory  apparatus;  their  manner  of  origin  is  centripetal. 

Owing  to  the  complexity  of  the  process  of  perception,  we  can 
understand  the  frequency  with  which  they  occur.  In  fact,  they  are 
everyday  phenomena  of  physiologic  life. 

Their  places  of  origin  may  be : — 

1.  External  space  through  which  the  physical  stimulus  has  to  pass  (phys- 
ical illusion). 

2.  The  peripheral  sensory  apparatus,  together  with  the  subcortical  organ 
-of  perception  (physiologic  illusion). 

3.  Cortical  organ  of  apperception  (psychic  illusion). 

1.  Illusions  that  have  their  cause  in  external  space  are  frequently 
caused  by  changes  in  the  media  through  which  the  external  stimulus 
has  to  pass  in  order  to  reach  the  sense-organ. 


112         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Thus,  objects  in  thin  air  seem  small  and  farther  away,  -nhile  the  same 
objects  in  a.  denser  atmosphere  seem  larger  and  nearer;  since  the  refraction  of 
the  rays  of  light  ■which  takes  place  when  they  pass  from  a  thinner  medium  to 
a  denser  is  increased,  and  rice  versa. 

Owing  to  the  physical  and  physiologic  peculiarities  of  the  eye,  in  riding 
in  a  railroad  train  the  trees  and  telegraph  poles  seem  to  fly  by  us,  while,  in 
fact,  we  hasten  by  them;  a  stick  thrust  into  the  water  seems  to  be  bentj 
bright  objects  seen  upon  a  dark  ground  seem  to  be  larger  than  they  are. 

2.  Inadequate  stimulation  of  the  sensory  nerves  is  an  important 
source  of  illusions.  Owing  to  its  specific  eneroy,.  the  sense-apparatus 
reacts  to  any  kind  of  stimulus  that  comes  in  contact  with  it,  with  the 
production  of  a  corresponding  sensory  impression. 

The  stimulation  caused  by  congestion  and  exudation,  as  they  occur 
in  the  clioroid  and  retina,  affect  the  optic  nerve  by  pressure  and  are 
answered  by  perceptions  of  light.  In  catarrh  of  the  middle  ear  or  of 
the  tubes,  noises,  rattling,  and  ringing  in  the  ear  occur. 

The  sense-apparatus  cannot  react  to  inadequate  stimuli  in  any 
other  way  than  with  elementary  qualities  of  sensation;  but  the  sub- 
jective sensation  may,  when  carried  to  the  cortex,  awaken  an  idea 
inadequate  for  the  sensation,  and  thus  induce  an  illusion. 

One  who  is  mentally  sound  and  in  full  possession  of  his  faculties 
may  experience  such  an  illusion :  but  he  interprets  the  subjective  sensa- 
tion correctly,  looks  upon  it  for  what  it  is,  and  concludes  that  the 
sense-apparatus  is  disturbed.  In  the  case  of  the  insane  person  whose 
consciousness  is  clouded,  it  is  otherwise;  it  is  only  too  easy  for  the 
subjective  excitement  to  become  transformed  fantastically,  owing  to 
want  of  clearness  and  the  existence  of  abnormal  emotions. 

Apparently  many  of  the  phenomena  in  the  insane  that  are  looked 
upon  as  hallucinations  are  to  be  explained  by  the  fact  that  at  first  the 
patient,  who  is  still  somewhat  clear  in  mind,  recognizes  the  subjective 
sensations,  and  perceives  them  as  flashes  of  light  and  roaring  in  the 
ear;  but  with  progressive  clouding  of  consciousness  he  turns  the 
flames  to  devils,  and  changes  the  sounds  into  threats  and  insults,  and 
thus  obtains  the  elements  for  visions  and  voices. 

This  is  especially  true  in  those  frequent  cases  in  which  the  hal- 
lucinations have  developed  out  of  j)hosphenes  or  noises,  and  are  still 
accompanied  by  subjective  states  of  excitement  of  the  sense-appara- 
tus, when  the  phantasma  or  acusma  is  localized  in  one  eye  or  one  ear 
and  disappears  when  the  eye  is  closed,  or  changes  its  location  in  the 
visual  field.  The  frequency  and  importance  of  these  "illusions"  make 
it  necessary  that,  whenever  such  uncertain,  stable  subjective  elementary 
sensations  are  associated  with  errors  of  the  senses,  the  corresponding 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    113 

sense-organ  should  be  carefully  oxainined  physically;  and,  in  the  case 
of  the  ear,  the  use  of  a  constant  current,  according  to  Brenner's  pro- 
cedure, is  especially  useful.^ 

3.  Frequently  enough  the  perceptive  sense-apparatus,  including 
the  organ  of  perception,  leaves  nothing  to  be  desired  in  normal  activity. 
Falsification  of  the  sensory  impressions  takes  place  only  in  the  center 
of  apperception;  the  illusion  is  psychically  conditioned.  The  cause 
of  this  psychic  origin  of  illusions  lies  partly  in  the  lach  of  attention 
and  partly  in  defective  perception,  and  sometimes  in  l)oth  simultane- 
ously. A  phenomenon  belouging  here  that  is  very  frequent,  and 
which  occurs  also  under  physiologic  conditions,  is  emotional  illusion. 
The  exactness  of  perception  in  these  cases  is  disturbed  by  the  fact  that 
thought  is  pre-occupied  with  a  certain  series  of  ideas.  The  sensory 
impression  reaching  the  organ  of  apperception  induces  an  idea  with 
an  accompanying  sense-picture  which  is  in  accord  with  the  state  of 
feeling,  but  which  does  not  correspond  with  reality,  and  it  is  projected 
externally  like  a  true  perception,  ^vithout  the  patient  becoming  aware 
of  his  error. 

Thus  is  explained  the  phenomenon  of  the  frightened  wanderer  in  a  lone- 
some forest,  who  takes  the  rustling  of  the  leaves  for  the  steps  of  pursuers  and 
robbers ;  how  one  troubled  with  the  fear  of  ghosts,  on  entering  a  cemetery  at 
night,  sees  behind  every  tombstone  the  ghost  of  a  departed  saint. 

Thus  it  happens  tlip^t  one  suffering  with  religious  exaltation  sees  in 
church  pictures  of  the  Virgin  nod  to  him,  or  the  eyes  of  the  image  of  the  Lord 
on  the  cross  turn,  etc.  Again,  in  the  state  of  anger,  the  gestures  and  words  of 
one  who  has  occasioned  it  are  looked  upon  as  insults  and  threats;  th&  person 
suffering  with  jealousy  looks  upon  the  most  harmless  signs  in  the  object  of 
his  jealousy  as  suspicious  and  interprets  them  falsely;  the  person  violently 
inflamed  with  love  perceives  the  object  of  his  aft'ection  in  an  ideal  way,  and 
sees  ugliness  in  the  light  of  beauty  (Don  Quixote  and  his  adventure  with 
Maritorne) ;  finally,  one  in  a  state  of  exaltation  might  take  windmills  for 
giants,  and  attack  them. 

A  second' source  of  illusions  lies  in  the  want  of  clearness  of  impres- 
sions, whether  this  be  due  to  want  of  attention,  distraction,  or  to 
flightiness  or  incompleteness  of  the  sensory  impression. 


*■  Brenner's  discovery  of  normal  galvanic  vertigo  has  been  followed  by 
most  thorough  study  of  vertigo,  normal  and  abnormal,  induced  by  galvanism, 
by  J.  Babinski;  vide  "Report  of  Observations  made  in  the  Clinic  of  Dr.  J. 
Babinski,  Paris,  by  C.  G.  Chaddock,  M.D.,"  American  Journal  of  Insanity, 
October,  1903.  Here  Avill  be  found  a  description  of  the  procedure  and  sugges- 
tions concerning  its  importance  as  a  means  of  diagnosis  in  cases  of  auditory 
hallucination,  with  the  remarkable  results  of  lumbar  puncture  in  cases  of 
tinnitus  aurium  and  deafness  due  to  disease  of  the  internal  ear. — Teanslator. 


114         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

In  this  category  there  is  a  great  number  of  phenomena.  Louking  at  the 
clouds  in  the  sky,  we  see  there  the  form  of  a  giant,  a  house,  or  a  ship.  The 
false  apperception  awakens  our  attention,  and  we  are  no  longer  able  to  see 
the  fantastic  oloiids  in  other  than  their  real  contour.s;  or,  as  we  go  along  the 
street  abstract-edly,  we  fancy  we  meet  an  acquaintance,  and  we  are  on  the 
point  of  speaking  to  him,  but,  our  attention  awakened,  we  remark  that  it  is  a 
stranger. 

This  kind  of  illusion  is  favored  very  much  by  physical  conditions  that 
interfere  with  the  clearness  of  impressions,  like  dusk,  moonlight,  fog,  etc. 
Under  such  circumstances  a  tree  may  be  mistaken  for  a  man ;  a  cluth  hanging 
out  of  a  window  for  the  body  of  a  man  hanging. 

Such  illusions  are  immediately  corrected  by  attention.  If  this  is  want- 
ing, as  when  the  illusional  impression  calls  up  the  emotion  of  fear  or  fright, 
then  the  illusion  remains  uncorrected. 

To  this  class  belong  those  illusions  that  are  frequently  to  be  observed  in 
the  maniacal,  in  whom  the  enormous  increase  in  the  rapidity  of  thought  makes 
impossible  the  quiet  consideration  and  judgment  of  impressions  coming  from 
the  external  world. 

A  further  source  of  illusions,  which  should  be  correctly  called 
deliria  of  judgment,  lies  in  the  fact  that  the  experience  required  for 
the  differentiation  of  similar  objects  may  he  wantius;  (as  in  the  child) 
or  have  been  lost  (as  in  states  of  mental  weakness). 

The  baby  looks  upon  every  male  person  that  comes  before  it  as  its 
papa,  because  differentiating  ideas  are  yet  wanting.  The  weak-minded 
or  paralytic  individual  gathers  up  small  shining  objects  because  he 
looks  upon  them  as  gold  and  precious  stones. 

Finally,  an  illusion  that  occurs  not  infrequently  in  the  insane  is 
due  to  the  fact  that  a  new  perception  is  not  only  similar  to  the 
original,  but  is  regarded  as  identical  by  the  individual.  Such  a  phe- 
nomenon depends  upon  Aveakness  of  memory  or  lessened  power  of 
identical  reproduction.  The  illusion  becomes  fixed,  owing  to  the  fact 
that  the  weakness  of  apperception  and  -weakness  of  control  which 
usually  exist  simultaneously  prevent  correction. 

Upon  this  depends  the  mistaking  of  persons,  not  infrequent  in  the 
insane;  which  differs  from  the  same  error  in  the  sane  due  to  im- 
perfect attention  and  abstraction,  in  that  in  the  former  it  is  constant, 
while  in  the  sane  it  is  transitory.  In  the  insane  this  anomaly  not  infre- 
quently persists  with  regard  to  certain  persons  for  weeks,  months,  and 
sometimes  throughout  the  whole  course  of  the  disease.  Evidently  in 
such  cases  there  are  certain,  usually  superficial,  points  of  resemblance 
between  the  person  present  and  the  weakened  memory-picture  of  the 
absent  individual  which  cause  the  error. 

The  psychologic  significance  of  illusion  is  the  same  as  that  of 
hallucination. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.     115 

If  correction  of  the  error  does  not  take  place,  then  all  possible 
results  of  a  false  perception  may  follow.  The  conditions  and  means 
of  correction  are  the  same  as  in  the  case  of  hallucination.  With  dis- 
turbance of  mental  clearness  and  of  the  activities  of  the  senses,  as  they 
exist  in  the  insane,  falsification  of  consciousness  by  illusions  is  very 
common. 

Deliria  of  the  Senses  in  the  Insane. 

After  these  introductory  remarks  it  remains  to  consider  deliria 
of  the  senses  (hallucinations  and  illusions)  as  they  occur  clinically, 
and  as  important  pathologic  elements  of  insanity.  In  this  we  must 
consider  them  with  reference  to  two  points : — 

1.  Their  frequency  and  peculiarities  as  manifest  in  the  various 
senses. 

2.  Their  peculiarities  and  frequency  in  the  various  forms  or  states 
o±  insanity. 

1.  When  we  seek  to  ascertain  the  frequency  of  errors  of  the  senses 
in  insanity  in  general,  we  at  once  come  upon  great  obstacles;  for 
certainly  they  occur  much  more  frequently  than  they  are  observed. 
Many  insane  persons  know  how  to  conceal  them,  just  as  they  do  their 
delusions.  Besides  this,  there  is  the  difficulty  of  differentiating  the 
errors  of  the  senses  from  simple  fancies,  deliria  of  judgment,  and 
delusions. 

The*  question  concerning  their  frequency  in  the  various  senses  is 
more  important.  While  in  the  sane,  aside  from  the  everyday  insignifi- 
cant illusions  that  are  immediately  corrected,  there  may  be  hallucina- 
tions of  sight  (visions)  and  very  rarely  hallucinations  of  hearing,  in 
the  insane  errors  of  the  senses  may  occur  in  any  sense — in  fact, 
sometimes  in  all  the  senses  at  the  same  time. 

In  frequency  hallucinations  of  sight  and  hearing  are  about  equal ; 
those  of  sight  are  observed  mainly  in  acute  insanity,  those  of  hear- 
ing most  frequently  in  chronic  insanity.  Hallucinations  of  smell  and 
taste  are  much  less  frequent.  In  the  domains  of  common  cutane- 
ous sensibility  and  general  sensibility  hallucinations  and  illusions 
cannot  be  very  readily  differentiated.  In  these  two  domains  errors  are 
decidedly  more  frequent  than  in  those  of  smell  and  taste.  The  most 
infrequent  phenomenon  is  that  of  simultaneous  hallucinations  (or  illu- 
sions) of  all  the  senses. 

Since  sense-deliria  are  expressed  thoughts  of  conscious  mental 
life,  or  are,  at  least,  projection  signals  influenced  by  the  state  of  feel- 
ing of  unconscious  psychic  activity,  in  general  they  are  in  harmony 
with  the  immediate  content  of  thought  and  feeling. 


nn         OEXERAL  rATlIOLOGY  AND  THERAPY  OF  INSANITY. 

Tlie  melancholic  person,  in  his  state  of  anxious  expectation,  sees  his 
pursuer,  his  executioner,  who  is  about  to  give  him  into  the  hands  of  the  law; 
tlie  melanciiolic  mother,  troubled  about  the  welfare  of  her  children,  hears 
their  cries  for  help,  the  death-rattle  in  their  throats;  the  maniac,  moving  in 
expansive  affect,  takes  pleasure  in  looking  at  his  air-castles  and  imaginary 
pleasures;  the  person  suffering  with  delusions  of  persecution  hears  the  whis- 
pering of  his  enemies  as  they  plan  to  destroy  liiin.  In  the  expression  of  those 
about  him  the  persecuted  patient  sees  signs  of  mutual  understanding;  in  food 
and  drink  he  tastes  poison;  in  unpleasant  cutaneous  and  general  sensations 
he  recognizes  the  nightly  activity  of  enemies  wlio  seek  to  destroy  his  life  and 
health  by  means  of  strange  machines.  The  religious  maniac  söes  heaven  open, 
is  blessed  by  the  apparition  of  heavenly  beings,  hears  songs  of  angels  and  the 
voice  of  God  giving  commands  and  speaking  wisdom,  etc. 

The  various  ways  in  which  those  having  hallucinations  of  hearing 
render  their  voices  objective  is  remarkable. 

In  some  cases — namely,  where  the  hallucination  is  the  i)lastic 
expression  of  clearly  conscious  ideas,  and  congruent  with  the  momen- 
tary content  of  thought — the  joatient  speaks  of  his  own  brain  as  the 
place  of  its  origin  (''It  is  something  that  takes  place  in  my  head^'). 
^Many  patients  speak  of  the  voices  they  hear  as  "loud  thinking'^  or 
"  thought-speech." 

Usually,  however,  liallucinations  of  hearing  are  projected  into  the 
external  world,  and  in  tlje  consciousness  of  the  patient  they  have  the 
value  of  a  real  auditory  perception.  '  Sometimes  the  voices  seem  to  be 
in  immediate  proximity  and  are  cried  into  the  ear — conditions  which 
make  it  probable  that  the  place  of  origin  of  these  pseudo-hallucinations 
is  the  organ  of  perception.  At  an}^  rate,  in  such  cases  there  is  usually 
coexistent  auditory  hyperesthesia,  with  elementary  subjective  sensa- 
tions due  to  exciting  processes  affecting  the  sense-apparatus. 

Less  frequently  the  patient  locates  the  voices  in  organs  of  the 
body  distant  from  tlie  brain;  for  example,  in  the  cliest  or  abdomen, 
where  apparently  and  usually  there  are  demonstrable  simultaneous 
abnonnal  sensations,  which  fix  the  attention  on  the  part,  and  thus  give 
rise  to  the  particular  localization. 

Ordinarily,  however,  the  voices  are  perceived  as  coming  from  the 
external  world,  like  actual  auditory  perceptions. 

With  relation  to  visual  Jtallucinafion  it  may  be  said  that  they  are 
especially  lively  and  frecpient  at  night  or  in  the  dark;  hence  the 
rule  that  the  room  in  which  a  patient  affected  with  visual  hallucination 
is  placed  should  never  be  entirely  dark.  Often  at  the  beginning  of  the 
disease  these  hallucinations  are  shadowy,  like  the  forms  in  a  shadow- 
play,  and  only  reach  plasticity  at  the  height  of  the  disease,  to  fade 
with  the  beginning  of  improvement.    They  may  become  so  continuous 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    117 

and  numerous  that  the  patient  moves  in  a  perfect  dream-world.  Then 
the  mask-like,  staring  features  and  breathless  fixation  of  a  single  point 
are  characteristic.  They  occur  with  especial  frequency  in  acute  condi- 
tions of  exhaustion  (anemia  of  the  central  organ)  and  in  forms  of 
alcoholic  insanity. 

Isolated  hallucinations  of  smell  and  taste  do  not  readily  occur.  It 
is  scarcely  possible  certainly  to  differentiate  the  former  from  olfactory 
sensations  brought  about  by  hyperesthesia  of  the  olfactory  nerve ;  and 
likewise,  frequently  as  the  basis  of  errors  of  taste,  there  may  be  an 
actual  gustatory  sensation,  dependent,  perhaps,  upon  gastric  or  buccal 
catarrh.  Almost  without  exception  the  hallucinations  of  taste  and 
smell  are  of  unpleasant  character.  The  patient  smells  cadaverous 
odors  or  sulphurous  gases;  the  food  tastes  of  copper,  arsenic,  human 
feces,  etc. 

Olfactory  hallucinations  are  remarkably  frequent  in  insanity  on 
an  onanistic  foundation,  as  well  as  in  connection  with  conditions 
dependent  upon  sexual  diseases  in  women^  especially  at  the  climacteric. 

In  the  domain  of  cutaneous  sensations,  illusions  and  hallucina- 
tions are  difllcult  to  differentiate.  For  the  most  part,  phenomena 
occurring  here  are  really  illusional  apperceptions  of  actual  sensations ; 
they  are  paresthesias  or  hyperesthesias  of  spinal  origin,  or  due  to 
rheumatic  affections,  eczemas,  variations  of  the  capillary  circulation, 
etc.,  which  become  the  basis  of  certain  organic  illusions  of  persecu- 
tion, like  the  delusions  of  being  magnetized  by  unseen  persons,  of 
being  covered  with  poison,  infected,  etc.  General  anesthesias  can 
sometimes  be  discovered  when  the  patient  thinks  he  is  dead;  or 
partial  anesthesias,  when  he  thinks  his  arms  and  legs  are  made  of 
glass  or  that  he  has  been  robbed  of  his  head  or  some  other  part  of 
his  body. 

In  patients  afflicted  Avith  hemianesthesia  there  is  sometimes  the 
delusion  that  another  person  or  a  corpse  lies  with  them  in  bed.  Thus, 
a  patient  of  Maudsley,  who  was  a  paralytic  and  suffered  with  hemi- 
anesthesia and  convulsions  of  the  same  side,  thought  another  person 
was  lying  beside  him  and  constantly  striking  him. 

The  delusion  of  flying  or  of  being  carried  away,  of  having  changed 
in  weight,  may  depend  upon  anomalies  of  the  muscle-sense ;  or  under 
such  circumstances  the  size  of  the  body  or  of  a  single  member  not 
infrequently  seems  changed. 

Also  in  the  domain  of  general  sensibility  illusions  and  hallucina- 
tions play  an  important  role,  especially  in  hypochondriacs.  In  these 
cases  it  is  difficult  to  separate  hallucinations  and  illusions.  The  first 
exist  when  the  abnormal  imagination  becomes  effective  as  a  stimulus. 


lis         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

and  the  imaginary  sensation  is  actnally  centrally  excited.  Illusions 
exist  when  abnormally  intensified  and  perverted  general  sensations 
reach  consciousness  and  are  tliere  erroneously  interpreled. 

This  result  can  quite  as  well  bo  due  to  a  louditiou  in  wliicli  tlic  organ  of 
consciousness*  lias  become  hyperestlu'tic,  ami  peneives  vegetative  processes 
which  normally  do  not  reach  consi-iuusness,  as  to  a  condition  in  which  an 
organic  sensation  has  become  pathologically  intensified,  and  thus  crosses  the 
threshold  of  consciousness.  As  a  rule,  we  have  here  to  deal  with  illusions. 
Autopsies,  as  Avell  as  careful  clinical  examinations,  often  enough  show  the 
substratum  of  hypochondriac  sensations  to  be  changes  in  the  position  and 
tissues  of  the  vegetative  organs.  Such  alterations  are  catarrh  of  the  digestive 
organs,  twists  and  abnormal  position  of  the  intestines,  obstipation,  hemor- 
rhoids, and.  chronic  inflammation  of  the  diaphragm  (one  of  Esquirol's  patients 
thought  he  had  a  whole  council  in  his  alxlomen,  and  at  the  autopsy  it  Avas 
shown  that  he  had  chronic  peritonitis).  Colicky  pains  are  also  etfectual  (a 
certain  Peter  Jurieu  thoxight  that  colicky  pains,  which  he  frequently  had, 
were  due  to  fights  which  seven  knights  had  in  his  stomach).  No  less  do 
infarcts,  catarrh,  new  growths  and  abnormal  positions  of  the  uterus,  and 
spermatorrhea  induce  similar  mental  anomalies. 

Thus,  in  the  JNIiddle  Ages,  abnormal  sexual  sensations  led  to  the  delusions 
of  incubus  and  suecubus.  Onanists  sometimes  have  the  illusion  that  semen  is 
taken  away  from  them  by  unseen  persons,  as  a  result  of  abnornuil  sensations 
in  the  urethra. 

The  frequency  of  such  illusional  interpretation  makes  it  necessary 
in  such  cases  to  make  a  very  careful  examination  of  the  organs 
involved. 

2.  With  reference  to  the  occurrence  of  sense-deliria  in  the  vari- 
ous forms  of  insanity,  distinction  is  to  be  made  between  acute  and 
chronic  forms.  In  acute  insanity  they  are  more  frequent  than  in 
its  chronic  forms,  and  in  the  former  visual  hallucinations  predom- 
inate over  auditory. 

In  melancholic  states  auditory  and  sensory  deliria  are  more  fre- 
quent than  those  of  sight.  They  are  most  frequent  in  melancholia 
activa  and  melancholia  attonita. 

In  the  acute  manias,  as  well  as  in  acute  hallucinatory  insanity, 
hallucinations  are  prominent  symptoms.  In  chronic  manias,  with  ex- 
ception of  the  puerperal  form,  they  are  infrequent. 

*     The  infrequency  of  sense-deliria  in  the  periodic  forms  of  mania, 
as  well  as  in  circular  insanity,  is  remarkable. 

In  states  of  paranoia  sense-deliria  are  very  frequent,  especially 
those  of  hearing;  and  then  those  of  sensibility  and  of  smell  and  taste, 
in  this  order  of  relative  frequency.  Visual  hallucinations  occur  epi- 
sodically, and  most  frequently  when  the  disease  is  developed  on  an 
alcoholic  basis. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    119 

In  case  of  religious-expansive  paranoia  hallucinations  of  hearing 
and  sight  are  very  common  ;  sometimes  they  become  so  intensified  tem- 
porarily as  to  induce  a  state  of  ecstasy. 

In  states  of  dementia  hallucinations  are  absent.  Here  illusions 
may  occur  upon  the  basis  of  imperfect  percepts  and  lost  criticism. 

Also  in  dementia  paralytica  sense-deliria  are  infrequent.  They 
are  more  frequently  observed  in  intercurrent  states  of  excitement,  and 
especially  in  those  that  are  depressive  in  character. 


CHAPTER  VIII. 
'  Disturbances  of  Sensory  Functions. 

These  disturbances  are  important  elements  of  insanity^  in  that 
they  form  the  substratum  for  delusions,  sense-deliria,  and  emotional 
states,  and  iriay  bring  about  paroxysms  of  insanity. 

The  examination  of  sensibility  in  insanity  is  usually  difficult, 
partly  because  of  defective  attention  and  changing  states  of  conscious- 
ness in  the  patient,  as  a  result  of  which  the  threshold  of  excitability 
is  continually  changed;  partly  on  account  of  the  changed  states  of 
circulation  in  the  vessels  of  the  skin,  for  anemia  of  the  skin  diminishes, 
and  hyperemia  increases,  tactile  sensibility. 

Functionally,  we  may  differentiate  as  follows : — 

1.  States  of  lessened  or  lost  excitability  and  excitation  (anes- 
thesias). 

2.  States  of  increased  excitability  and  excitation  (hyperesthesias 
and  neuralgias). 

1.  Anesthesias. 

Anesthesia  may  be  psychically  a  result  of  loss  of  apperception  in 
the  psychic  organ;  organically,  a  result  of  destruction  of  conducting 
paths  and  peripheral  sense-organs. 

As  a  rule,  we  have  to  deal  with  disturbed  apperception  associated 
with  integrity  of  nervous  conducting  paths. 

(a)  Anesthesias  of  the  Sense-organs. — The  psychic  anes- 
thesia which  results  from  absence  of  the  emotional  coloring  which  nor- 
mally accompanies  a  sense-perception  has  already  been  alluded  to  in 
connection  with  anomalies  of  the  emotions.  The  accompanying  pleas- 
ant or  unpleasant  feelings  in  the  hysteric  may  be  perverse  (idios}Ti- 
crasies).  It  remains  to  mention  here  the  loss  of  sensation  in  itself. 
■  As  a  rule,  this  is  a  disturbance  of  apperception  due  to  the  loss  of  the 
psychic  element  in  the  sensory  processes  (defect  of  consciousness,  want 


120    GENERAL  rATHOLOGY  AND  TUEÜArY  OF  INSANITY. 

of  attention),  and  thus  it  is  observed  in  stupor,  maiiia,  idiocv,  patho- 
logic dream-states,  etc.  Less  frequently  it  is  of  an  organic  nature  and 
due  to  destruction  of  the  cortical  center,  the  conducting  paths,  or 
degeneration,  of  the  sense-organ  (amblyopia  and  amaurosis  as  expres- 
sion of  diseases  of  the  retina,  genetic  relation  of  which  with  insanity 
is  to  be  sought  in  common  vasomotor  sympathetic  diseases;  anosmia 
due  to  degeneration  of  the  olfactory  bulbs,  often  found  in  paralytics). 

(b)  AXESTIIESIA  OF  CuTANEOUS  AND  MuSCULAR  SENSIBILITY. — 

The  first  may  aifect  the  pain,  tactile,  and  temperature  senses.  Usually 
it  is  psychically  conditioned,  and  frequently  one  of  the  symptoms  of 
the  hysteric  neurosis;  less  frequently  it  is  due  to  degenerative  dis- 
eases of  the  spinal  cord  (dementia  paralytica)  and  focal  brain  diseases. 

The  loss  of  the  pain-sense  is  of  great  significance  in  insanity.  As 
a  rule,  the  analgesia  is  psychically  induced,  as  a  result  of  the  inexcita- 
bility  of  the  psychic  organ.  Physiologic  life  presents  analogies,  as  in 
the  case  of  the  soldier,  who,  in  the  thick  of  the  fight,  is  wounded  and 
does  not  know  it;  or  of  the  martyr,  who,  because  of  his  religious 
ecstasy,  does  not  feel  wounds  and  torture. 

The  clinical  significance  of  analgesias  in  insanity  is  great,  since 
they  may  lead  to  intentional  self-injury,  brutality  in  the  manner  of 
carrying  out  suicide,  and  finally  to  accidents  (burning). 

Thus  there  are  patients  who  crucify  or  castrate  themselves, 
or  cause  themselves  to  be  torn  to  pieces  by  horses.  Lack  of  sensi- 
bility to  cold  is  usually  psychic,  and  occurs  especially  in  the  maniacal 
and  demented.  It  is  owing  to  this  anomaly  that  such  patients 
run  about  without  clothes.  In  anemic  states,  on  the  other  hand,  there 
is  usually  an  increased  desire  for  heat. 

The  feeling  of  many  patients  of  having  changed  in  weight,  of 
being  abnormally  light,  of  being  of  abnormal  size  either  in  body  or  in 
certain  members,  usually  depends  upon  diminished  muscular  sense. 
If  the  cutaneous  and  muscular  senses  be  simultaneously  lost,  then  the 
patients  have  the  feeling  that  they  have  absolutely  lost  the  portion  of 
the  body  concerned ;  if  the  anesthesia  be  general,  consciousness  of  per- 
sonality may  be  wanting  and  the  patient  think  himself  dead. 

(c)  Anesthesias  of  General  Sensibility. — Anomalies  of  this 
kind  have  been  but  little  investigated,  but  they  are  to  be  referred,  for 
the  most  part,  to  psychic  elementary  disturbances  of  consciousness. 
Here  belong  the  defective  feeling  of  hunger,  thirst,  physical  fatigue 

(mania),  and  defective  feeling  of  illness  in  severe  intercurrent  dis- 
eases (walking  typhoid,  pneumonia) ,  Certain  nihilistic  hypochondriac 
delusions  concerning  the  disappearance  or  lack  of  organs,  as  they 
occur  in  dementia  paralytica  and  senilis,  are  also  due  to  anesthesias. 


ELEMENTARY  ANOMALIES  OF  THE  CEREHRAL  FUNCTIONS.    121 

Complaints  of  the  insane,  and  Gs^jecially  of  niolancholics,  of  feel- 
ing empty,  of  being  hollow,  or  of  pressure  in  the  head,  of  drying  up 
of  the  brain,  or  of  having  air  or  water  on  the  brain,  and  the  like, 
require  more  exact  investigation. 

Many  of  these  sensations,  that  are  partly  direct  and  partly  alle- 
goric interpretations  of  sensations,  are  to  be  referred  to  anomalies  of 
the  scalp  (feeling  of  inhibition  of  thought  in  paralysis  of  the  occipital 
nerves),  or  perhaps  to  anomalies  of  the  recurrent  trigeminal  nerves ; 
others  are  due  to  disturbances  of  general  sensibility  which  have  their 
foundation  in  anatomic  processes  forming  the  basis  of  the  psychosis, 

2.  Hyperesthesias.' 

These  disturbances  are  much  more  frequent  and  important  in 
the  insane  than  the  anesthesias.  They  may  be  due  to  changes  in  the 
excitability  of  the  peripheral  organs,  the  conducting  paths,  or  the 
central  psychic  apparatus.  Their  common  characteristic  is  the  ab- 
normally deep  threshold  of  stimulation  for  adequate  stimuli.  In 
these  conditions  the  psychic  element  of  mental  tension  plays  an 
important  role,  like  that  seen  in  case  of  emotional  expectation. 

(a)  Hypeeesthesias  of  the  Higher  Sense-organs. — Here 
emotional  coloring  and  intensity  of  sensibility  must  be  differentiated. 
The  former  expresses  itself  in  potentiated  feelings  of  pleasure  and 
displeasure,  and  is  found  in  states  of  psychic  exaltation  (mania,  states 
of  hysteric  excitement). 

The  abnormally  intense  excitation,  as  a  rule,  occurs  with  the  first 
phenomenon;  often  also  with  manifestations  of  irritation  induced  by 
inadequate  stimuli,  which  affect  the  peripheral  sense-oragn  or  its  con- 
ducting path  (hyperesthesia  of  the  optic  nerve,  with  photopsia  and 
chromatopsia ;  hyperacusis  with  subjective  noises). 

For  the  most  part,  hyperesthesia  is  due  to  increased  excitability 
of  the  peripheral  sense-organ  or  its  conducting  path;  less  frequently 
to  such  a  state  of  the  organ  of  apperception.  It  occurs  as  one  of  the 
symptoms  of  general  intensification  of  excitability  in  mania,  acute 
delirium,  hypochondria,  and  hysteria. 

(l)  Hyperesthesias  in  the  Domain  of  Cutaneous  Sensi- 
bility.— They  occur  in  various  insane  states.  Their  foundation  is 
less  frequently  psychic  than  organic  (increased  excitability  of  the 
peripheral  end-organ  and  the  conducting  paths). 

Circumscribed  hyperesthesias  are  found  to  occur  not  infre- 
quently in  melancholies,  and  cause  such  patients  to  rub  the  skin  until 
it  is  injured. 


122         GENERAL  PATHOLOGY  j\ND  THEUAPY  OF  INSANITY. 

Hyperesthetic  conditions  of  spinal  origin  are  frequently  reflected 
SA'mptoms  of  irritntioh  in  the  sexual  organs  in  women;,  and  in  men 
are  due  to  onanistie  excesses. 

With  paralgic  sensations,  they  form  the  foundation  for  delusions 
of  being  persecuted  with  electricity  and  magnetism  by  unseen  persons; 
of  being  pricked  with  needles;  of  being  surrounded  with  poisonous 
gases  and  the  like. 

Probably  tlie  troublesome  feeling  of  pulsation  of  the  vessels  which 
occurs  in  hypochondria,  melancholia,  and  hysteria  is  to  be  referred  to 
hyperesthesia  of  the  nervi  vasorum;  certain  conditions  of  nervous 
cardiac  palpitation  to  hyperesthesia  of  the  sensory  nerves  of  the 
cardiac  region.  Hyperesthesia  of  the  muscle-nerves  may  be  the  cause 
of  the  painful  muscular  unrest  (anxietas  tibiarum)  that  not  infre- 
quently is  troublesome  in  the  hysteric,  hypochondriac,  and  melan- 
cholic. 

(c)  Htpeeesthesia  in  the  Domain  of  General  Sensibil- 
ity.— This  is  essentially  an  elementary  disturbance  in  hypochondria. 

Hypochondria  may  be  due  to  central  causes,  in  that  the  excita- 
tion of  vegetative  nerves,  which  ordinarily  are  reflected  into  conscious- 
ness in  the  form  of  feelings,  enter  consciousness  Avith  clearness;  or  it 
may  arise  peripherally,  when  local  affections  of  the  vegetative  organs 
produce  abnormal  excitation  of  their  nerves,  which  is  then  communi- 
cated to  consciousness. 

The  first,  or  psychic,  manner  of  origin  of  hypochondriac  states  is 
facilitated  by  psychic  tension  and  direction  of  the  patient's  attention 
to  physical  conditions.  The  second  may  be  due  to  gastro-intestinal 
catarrh;  to  sexual  diseases,  especially  onanism,  gonorrhea,  etc.;  and 
to  conditions  that  induce  a  localized  feeling  of  disease  rather  than 
actual  pain. 

In  cases  having  this  origin  the  hyperesthesia  is  originally  periph- 
eral, but  it  does  not  last  long  before  irradiation  of  the  irritation 
takes  place,  and  thus  it  becomes  psychic  (secondary  hyperesthesia), 
with  the  formation  of  a  vicious  circle. 

j\Ierely  an  idea  suffices  to  induce,  in  this  degree  of  psychic  hyper- 
esthesia, the  corresponding  sensation,  with  concomitant  excitement  of 
the  corresponding  nervous  paths  (cases  of  psychic  hydrophobia — the 
patient,  having  been  bitten  or  touched  by  a  dog  supposed  to  be  mad, 
imagines  that  he  has  been  infected,  and  soon  develops  the  symptoms 
of  hydrophobia,  a  true  hypochondriac  hydrophobia)  ;  just  as  peripheral 
excitation  of  the  nerves  of  general  sensibility  due  to  local  diseases  of 
the  organs  induces  adequate  ideas  in  consciousness.  Therefore  Eom- 
berg  justly  says:    "The  sensations   of  these  patients   are^  indeed, 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    123 

imagined,  but  they  are  projected  from  the  mind  to  the  body."  As  far 
as  consciousness  is  concerned,  it  is  a  matter  of  indifCerence  whether 
the  sensation  is  objective  or  subjective;  whetliet-  the  excitation  is 
peripheral  or  arises  at  the  central  end  of  the  apparatus. 

(d)  States  of  Abnormal  Excttatjon  in  tjib  Paths  of  tuk 
Sensory  Kerves  (Neuralgias). — Frequently  neuralgias  accompany 
insanity.  They  may  be  widespread  or  limited.  Especially  frequent 
and  important  are  intercostal,  lumbar,  occipital,  and  trigeminal  neu- 
ralgias. They  are  due  to  the  disturbances  of  nutrition  in  the  nervous 
system  common  to  neuralgias  and  insanity  (anemia,  etc.)  ;  and  they 
are  of  symptomatic  significance  in  the  disease-picture,  or  they  stand  in 
narrower  functional  relation  with  the  psychosis,  and  are  co-ordinate 
S3rmptoms,  probably  to  be  regarded  as  projected  symptoms. 

The  functional  value  of  neuralgia  is  explained  in  four  ways : — 

1.  It  is  almost  without  significance  as  far  as  the  psychic  life  is 
concerned,  and  at  the  most  has  an  influence  only  upon  mood  and  well- 
being,  just  as  in  the  sane.  Neuralgia  occurs  along  with  the  psychosis, 
but  without  any  relation  to  it. 

2.  It  forms  the  organic  substratum  of  some  delusion  that  has 
arisen  in  the  way  of  allegorization,  as  in  the  case  of  other  anomalies 
of  sensibility. 

3.  It  occurs  in  connection  with  elementary  psychic  disturbances, 
and  induces  them  by  irradiation  of  the  neuralgic  irritation  to  corre- 
sponding centers.  If  these  centers  be  sensorial,  ideational,  or  affective, 
like  the  accompanying  sensations  in  simple  neuralgia,  hallucinations 
and  ideas  having  the  character  of  imperative  concepts  may  be  induced, 
and  affective  states  may  likewise  result. 

Myodj^nias  may,  under  some  circumstances,  play  the  role  of  neu- 
ralgias. 

Not  infrequently  here  a  peculiar  vicious  circle  is  formed,  in  that  not 
only  the  neuralgia,  which  is  constantly  recurring,  induces  again  and  again  the 
psychic  elementary  disturbance,  but  the  latter  may  again  excite  the  neuralgia 
in  the  paths  which  were  primarily  responsible  for  the  association.  Schule, 
in  a  work  which  has  unfortunately  received  too  little  recognition,  has  laid 
emphasis  upon  this  important  psychic  fact  ("Die  Dysphrenia  Neuralgica," 
1867).  This  relationship  is  seen  with  especial  clearness  in  a  group  of  patients 
whom  Falret  describes  as  affected  with  "moral  hypochondria  ^Yith  conscious- 
ness of  the  condition."  Here,  with  exacerbation  of  the  nervous  symptom- 
complex,  the  irritable,  painful  emotional  state  is  regularly  intensified.  The 
time  of  the  menses  (temporarily  increased  excitability  of  the  psychic  organ) 
induces  this,  and  thus  leads  to  exacerbation  of  the  psychosis. 

4.  The  recrudescence  of  neuralgia  leads  to  formal  psychic  attacks : 
reflex  psychosis,  dysthymia,  or  dysphrenia  neuralgica,  in  its  narrower 


124         GENERAL  TATHOLOGY  AND  TIIERArY  OF  INSANITY. 

souse  (Öcliülo,  (Jriesiuger).  Such  unusual  excitability  of  the  ccniral 
organ  points  to  grave  anomalies  of  it.  In  fact,  this  d3^sphrenia  neu- 
ralgica  is  observed  in  individuals  ^vho  suffer  with  a  neurosis,  either 
hereditary  ("^burdened"),  hysteric,  hypochondriac,  or  epileptic.  In 
such  cases  tbe  neuralgia  may  hv  looked  upon  sometimes  as  an  aura, 
sometimes  as  an  equivalent  lor  an  outbreak  of  the  neurosis;  at  least, 
in  cases  of  epilepsy  these  neuralgic  attacks  leave  no  doubt  concerning 
the  correctness  of  this  view.  The  whole  process  may  be  regarded  as 
analogous  with  the  epileptic  delirium  that  follows  a  true  epileptic  con- 
vulsion. 

The  single  attack  of  neuralgic  dysphrenia  may  occur  clinically  as 
an  hallucinatory  delirium,  a  pathologic  affect,  angry  mania,  or  raptus 
melancholicus.  Here,  too,  the  neuralgic  element  may  undergo  alle- 
goric elaboration  in  becoming  the  nucleus  of  delusions,  which  then  in 
every  following  attack  return  in  their  typic  form.  In  such  a  case  a 
vicious  circle  also  may  arise,  in  which  the  psychic  attack,  however 
provoked,  immediately  causes  implication  of  the  neuralgic  nerve-a'rea. 


CHAPTER  IX. 
Disturbances  of  Motor  Functions. 

In  the  first  place,  and  as  following  disturbances  of  the  psycho- 
motor sphere,  we  must  recall  the  fact  that  the  whole  voluntary  muscu- 
lar system  is  kept  constantly  in  excitement  by  psychic  processes,  and 
that  upon  this  excitation  not  only  physiognomonic  expression,  but  also 
attitude,  intonation,  timbre  of  the  voice,  etc.,  depend.  This  psycho- 
motor innervation  is  changed  by  abnormal  psychic  processes,  and  the 
alteration  is  reflected  in  the  outward  manifestations  of  the  patient. 
It  is  recognized,  again,  as  changed  muscle-tone  in  the  diseased  con- 
sciousness. It  may  be  stated  that  every  psychopathic  state,  like  the 
physiologic  states  of  emotion,  has  its  own  peculiar  facial  expression 
and  general  manner  of  movement,  which  for  the  experienced,  on 
superficial  observation,  make  a  probable  diagnosis  possible. 

The  detailed  description  of  these  physiognomonic  types  as  they  are 
found  in  changes  of  the  glance,  expression,  and  general  attitude  of  the  body, 
cannot  be  described;  and  even  photographs  are  but  poor  siibstitutes  for  direct 
observation. 

Their  analysis  cannot  be  attempted  here,  but  examples  may  be  men- 
tioned: the  troubled,  wrinkled  mien  of  the  depressed  hj^pochondriac ;  the 
changing  physiognomy  of  the  maniac,  subject  to  all  sorts  of  emotional  im- 
pressions;   the  confused  expression  of  the  paranoiac;    the  swimming  ej'es  of 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    125 

the  hysteric  and  erotic;  tlio  bent  head  and  shuffling  gait  of  the  melancholic; 
the  proud  step  of  the  person  suffering  with  grand  ideas;  the  shuffling,  careless 
gait  and  foolish  laugh  of  the  demented.  In  states  of  mental  weakness  (de- 
mentia pai-alytica,  multiple  sclerosis)  I  have  sometimes  observed  paramimia, 
wliere  patients  who  felt  joyful  have  expressed  it  by  a  weeping  mien,  and  vice 
versa. 

Another  important  group  of  motor  disturl)ances  are  those  due  to 
fimctional  anomalies  of  the  motor  centers  and  the  conducting  paths, 
and  also  to  manifestations  of  ahnormal  reflex  excitability. 

Consideration  of  them  is  of  no  small  value  in  diagnosis  and  prog- 
nosis. 

They  may  be : — 

1.  Pre-existent — the  result  of  previous  nervous  diseases  (tremor, 
facial  spasm)  or  of  congenital  anomalies  (inequality  of  facial  innerva- 
tion, etc.,  as  functional  signs  of  degeneracy) . 

2.  They  may  arise  simultaneously  with  the  psychic  disease: — 
(a)  As  complicating,  and  due  to  general  disease  (anemia),  to  a 

neurosis  (chorea;  hj-steria,  epilepsy),  or  to  focal  diseases  standing  in 
relation  to  the  psychosis  (cerebral  tumor,  apoplexy). 

(h)  Co-ordinate  Avith  psychic  symptoms  and  due  to  the  same 
anatomic  process  that  induces  the  latter  (dementia  paralytica,  acute 
delirium). 

In  such  cases  thcj  may  be  due  to  changes  in  the  reflex,  automatic, 
and  psychomotor  centers;  to  disturbances  of  conduction  in  the  motor 
paths;  to  sensory  functional  disturbances  and  abnormal  reflexes  thus 
induced.     All  possible  functional  disturbances  may  occur  here. 

1.  Paralyses  as  a  result  of  focal  or  diffuse  diseases  of  the  brain 
and  spinal  cord  (dementia  paralytica  and  dementia  senilis,  chronic 
alcoholism,  acute  delirium) ;  the  paralyses  that  occur  in  the  domain 
of  the  hypoglossus,  facial,  and  motor  oculi  nerves  are  especially  im- 
portant; also  disturbances  of  deglutition  as  bulbar  symptoms  in  the 
flnal  stages  of  dementia  paralytica  and  acute  delirium. 

2.  Spasms  due  to  capillary  anemia  of  motor  centers  (vascular 
spasm,  edema),  or  to  intensified  reflex  excitability.  In  this  category 
belong  many  disturbances  of  deglutition  in  acute  delirium  and  hysteria. 
A  form  of  cramp  that  is  not  infrequent  in  insanity  is  that  called  grind- 
ing of  the  teeth  (motor  portion  of  trigeminus),  which  is  often  observed 
in  dementia  paralytica,  hydrocephalic  idiocy,  and  acute  delirium. 

3.  Contractures  in  idiots,  as  a  result  of  brain  defect  or  brain  dis- 
ease; in  focal  diseases  (apoplexy  and  sclerosis)  ;  sometimes  also  fol- 
lowing a  too  prolonged  use  of  the  jacket  or  maintenance  of  a  fixed 
attitude. 


126         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

4.  Tremor  due  to  anemia,  alcoholic  intoxication,  organic  brain 
affections  (dementia  paralytica,  sclerosis),  and  sometimes  also  as  a 
result  of  excitement  (fear). 

5.  Disturbances  of  co-ordination  due  to  organic  changes  in  the 
co-ordinating  mechanism ;  loss  of  ideas  of  movements  and  of  muscular 
feeling  (dementia  paralytica,  acute  delirium).^ 


CHAPTER  X. 
Disturbances  of  the  Vasomotor  Nerves. 

The  importance  of  anomalies  of  this  character  will  be  understood 
when  we  consider  the  fact  that,  whenever  states  of  psychic  emotion 
occur,  the  vasomotor  nervous  system  is  involved. 

The  circumstance  that  such  affects,  especially  fright,  may  imme- 
diately induce  a  psychosis,  of  course,  upon  the  foundation  of  special 
predisposition,  lends  to  the  vasomotor  anomalies  of  innervation,  which 
form  the  connecting  link  between  cause  and  effect,  a  high  pathogenic 
significance. 

Moreover,  clinical  observation  justifies  the  assumption  that  numer- 
ous psychoses  are  founded  upon  angioneuroses  of  the  brain.  In  certain 
melancholic  states,  associated  with  a  small,  contracted  pulse;  with  a 
cool,  dry,  rough,  scaly,  wrinkled  skin,  devoid  of  turgor ;  with  livid,  and 
even  cyanotic,  extremities — evidently  we  have  to  deal  Avith  a  neuro- 
pathic state  of  innervation  of  the  arteries,  and  consequent  disturbances 
of  nutrition  of  the  brain;  in  many  cases,  especially  in  melancholia 
with  stupor,  the  vascular  spasm  induces  secondary  venous  stasis,  that 
may  reach  the  degree  of  edema. 

On  the  other  hand,  in  many  maniacal  persons — that  is,  in  the 
grave  form  of  alcoholic  mania,  and  in  states  of  maniacal  excitement 
in  paralytics — we  meet  with  symptoms  which  point  to  a  condition  of 
vascular  paralysis,  and  consequent  fluctionary  cerebral  hyperemia. 

Without  doubt,  anomalies  of  vasomotor  innervation  are  of  the 
greatest  importance  in  the  pathogenesis  and  clinical  course  of  dementia 
paralytica.  In  these  cases  there  is  demonstral^le  (sphygmograph)  pro- 
gressive paralysis  of  the  vessels,  Avhich  even  in  the  earlier  stages  may 
show  itself  in  the  form  of  a  slow  monocrotic  pulse  or  in  an  extreme 
degree  of  vascular  paralysis.  Such  vascular  paralyses,  often  imilateral, 
are  quite  analogous  with  the  phenomena  induced  by  section  of  the 


^  The  numerous  investigations  of  electric  excitability  in  the  insane  have 
thus  far  given  no  results  and  have  no  diagnostic  value. 


ELEMENTARY  AlfOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    1 27 

cervical  sympathetic  after  the  method  of  Claude  Bernard,  and  they 
occur  in  the  various  stages  of  paralysis.  They  are,  without  doubt, 
important  causal  elements  in  the  variations  of  blood-pressure  upon 
which  the  apoplectiform  attacks  depend,  as  well  as  in  the  attacks  of 
maniacal  excitement  which  frequently  run  their  course  in  the  form  of  a 
vascular  storm. 

Too,  in  these  cases  amyl  nitrite  induces  exquisite  vascular  paraly- 
sis, while  in  case  of  melancholia  with  neuropathic  vascular  symptoms  it 
has  scarcely  any  effect  at  all. 

Another  important  elementary  disturbance  in  insanity  should 
probably  be  regarded  as  a  vasomotor  disturbance,  since  such  disturb- 
ances seem  to  induce  the  symptom-complex  in  question,  and,  at  any 
rate,  form  an  integral  element  of  it.  This  is  the  so-called  pre- 
cordial anxiety :  i.e.,  a  state  of  anxious  emotional  expectation  asso- 
ciated with  painful  feelings  of  pressure  and  distress  in  the  cardiac 
region. 

The  first  point  to  detei-mine  is  the  interrelation  of  the  two  phenomena. 
It  is  possible  that  these  paralgic  sensations  in  the  epigastrium  are  the  ex- 
pression of  a  primary  excitation  of  sensory  nerves,  this  state  of  excitement 
being  conducted  to  consciousness  and  there  inducing  a  feeling  of  anxiety;  or 
it  may  be  that  for  the  psychic  process  they  are  simultaneous  and  co-ordinated 
states  of  excitation  in  central  sensory  nerves,  this  excitement,  according  to 
the  law  of  eccentric  projection,  being  carried  to  the  peripheral  ends  of  the 
conducting  path. 

With  considerable  certainty  we  may  assume  that  the  affected  nervous 
paths  are  those  belonging  to  the  heart.  The  circumstance  that  the  precordial 
sensation  is  vague  and  not  definitely  located  would  indicate  a  neurosis'  of  the 
visceral  nervous  paths.  Besides,  pointing  to  the  same  conclusion,  there  are 
the  constant  localization  of  the  sensations  accompanying  the  feeling  of  anxiety 
in  the  region  of  the  heart;  the  fact  that  precordial  anxiety  is  always  asso- 
ciated with  disturbed  cardiac  innervation  (palpitation,  irregularity  of  the 
heart's  action,  anomalies  of  the  pulse,  shooting  pains  in  the  heart) ;  the  pre- 
cordial anxiety  in  poisoning  by  certain  poisons  that  especially  affect  the  heart 
(nicotine) ;  and  finally  its  occurrence  as  the  principal  symptom  in  an  un- 
doubted neurosis  of  the  heart  (angina  pectoris). 

Precordial  anxiety,  as  experience  teaches,  may  be  induced  by  psychic 
stimuli,  such  as  frightful  ideas,  apperceptions,  and  emotions,  and  thus  it  may 
be  of  central  origin;  or  it  may  be  caused  by  neuralgias,  and  thus  be  of 
peripheral  origin. 

Consideration  of  the  first  manner  of  origin  explains  the  facts  that  the 
nervous  system  of  the  heart  is  in  significant  dependence  upon  certain  psychic 
processes  (palpitation  in  emotional  states),  and  that  under  physiologic  condi- 
tions affects,  in  harmony  with  their  quality,  may  be  accompanied  by  feelings 
of  precordial  oppression  or  its  opposite. 

The  peripheral  manner  of  origin  is  to  be  explained  only  by  ii-radiation  of 
a  sensory  stimulus  to  the  nervous  system  of  the  heart. 


128         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Precordial  anxiety,  in  fact,  is  only  observed  in  states  of  excitation  of  the 
visceral  sensory  nerves;  never  as  a  result  of  neuralgic  aflfections  of  the  spinal 
nerves.'  This  exclusive  relation,  as  well  as  the  regular  simultaneous  affection 
of  the  cardiac  nerves  in  the  form  of  precordial  distress,  Romberg,  as  is  well 
known,  established  as  a  difl'erential  point  between  neuralgia  of  the  spinal 
nerves  and  of  those  of  tlie  symiiathetic  system. 

Thus,  precordial  anxiety  seems  to  arise  when,  as  a  result  of  psychic  irri- 
tation or  of  transference  of  a  state  of  irritation  in  the  visceral  nervous  paths, 
the  vasomotor  nerves  of  the  cardiac  muscle  are  thrown  into  a  state  of  intense 
excitement,  and  vascular  spasm  is  thus  induced. 

The  consequent  disturbed  function  of  the  automatic  ganglia  of  the 
cardiac  muscle  is  conducted  by  sensory  nerve-fibers  of  the  heart  to  the  organ 
of  consciousness  and  there  induces  the  feeling  of  anxiety,  which  is  then  pro- 
jected to  its  place  of  origin.  Too,  the  dreadful  pain  with  which  precordial 
anxiety  is  frequently  initiated  may  be  due  to  excitation  of  sensorj'  fibres  in 
the  vagus  and  sympathetic  of  the  cardiac  region,  while  the  simultaneous 
palpitation  is  explained  by  interference  with  the  supply  of  arterial  blood  to 
the  heart-muscle,  and  consequent  disturbances  of  innervation. 

The  feeling  of  globus,  or  of  closing  up  of  the  throat,  that  accompanies 
precordial  anxiety j  a  peculiar  uncertainty  of  the  voice,  which  sometimes  is 
entirely  lost;  and  the  superficial,  frequent  respiration  are  to  be  regarded  as 
reflected  symptoms  in  the  path  of  the  vagus  (glossopharyngeal,  superior  laryn- 
geal). The  suppression  and  subsequent  increase  of  perspiration  and  urine  are 
to  be  explained  by  the  spasmodic  disturbance  of  the  circulation. 

The  remarkable  fact  that  in  sane  persons  precordial  anxiety  is  only  ex- 
ceptionally accompanied  with  painful  ideas  is  easily  explained  when  we  remem- 
ber that,  as  in  the  majority  of  neuroses,  a  predisposing  factor,  an  increase  of 
excitability,  is  necessary  for  the  origin  of  the  abnormal  disturbance. 

Such  a  result,  however,  always  follows  where  a  psychic  stimulus  induces 
precordial  anxiety  of  any  duration  and  intensity  (hysteria,  epilepsy,  melan- 
cholia,-hypochondria,  chronic  alcoholism,  hydrophobia). 

The  precordial  anxiety  appears  then  as  a  pathologic  intensification  of  a 
phenomenon  that  occurs  under  physiologic  conditions,  when  psychic  emotions 
reach  the  intensity  of  affects,  in  nervous  paths  standing  in  close  relation  with 
psychic  life. 

The  psychic  significance  of  precordial  anxiety  is  very  great.  As 
a  result  of  the  intense  organic  coloring  of  the  affect  which  induces  it, 
it  leads  to  unbearable  intensification  of  the  emotional  condition.  In 
the  sphere  of  ideation  it  has  a  paralyzing,  inhibiting  effect,  bringing 
about  confusion  or  even  loss  of  the  power  of  apperception;  or  it 
induces  frightful  deliria  and  hallucinations. 


'  Intense  intercostal  neuralgias,  owing  to  the  fact  that  they  hinder  move- 
ment of  the  thorax,  like  valvular  disease  and  emphysema,  cause  mechanical 
obstacles  to  expansion  of  the  lungs,  and,  of  course,  interference  with  breath- 
ing; but  they  do  not  induce  precordial  anxiety.  But,  with  intercostal  neu- 
ralgia, precordial  anxiety  may  be  localized  and  felt  at  the  seat  of  the  neuralgia, 
and  become  the  object  of  attention. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    129 

On  the  motor  side  it  imperatively  drives  to  some  act  that  will 
overcome  the  resulting  state  of  psychic  tension;  and — depending  upon 
its  intensity,  the  suddenness  of  its  occurrence,  and  the  depth  of  the 
disturbance  of  consciousness — it  is  expressed  in  violent,  purpose- 
less running  about,  or  impulsive  acts  that  are  hardly  conscious,  and 
which  find  a  motive  only  in  a  dim  consciousness  of  the  need  of  a 
change  of  the  psychic  situation  at  any  cost;  or  they  may  lead  finally 
to  blind  ravings,  true  psychic  convulsions,  comparable  to  those  uncon- 
scious, violent  motor  explosions  that  characterize  an  epileptic  attack. 

Frightful  self-mutilations,  suicide,  murder,  wild  destruction  of 
everything  that  the  patient  can  lay  hands  on,  are  frequent  events,  and 
are  to  be  understood  as  due  to  the  horrible  fear,  the  profound  dis- 
turbance of  consciousness,  and  the  analgesia. 

During  an  attack  the  influence  of  such  acts  to  bring  relief  is 
remarkable. 

Precordial  anxiety  occurs  as  an  intercurrent  symptom  in  the 
course  of  the  neuroses  and  psychoses  previously  mentioned,  or  as  an 
independent  attack  lasting  minutes  or  hours  (raptus  melancholicus). 


CHAPTER  XI. 
Disturbances  of  the  Trophic  Functions. 

The  domain  of  the  trophic  functions  has  been  but  partially  inves- 
tigated by  physiology.  The  relationship  between  trophic  disturbances 
and  diseases  of  the  central  organs  of  the  nervous  sj^stem  is  not  imme- 
diately demonstrable. 

However,  it  is  possible  to  cite  in  favor  of  such  a  relationship  a 
number  of  congenital  defects  of  formation  and  development  of  the  body 
in  individuals  of  abnormal,  usually  hereditarily  conditioned,  brain 
organization  and  development,  which  are  also  revealed  by  a  number 
of  functional  anomalies. 

Among  such  anatomic  signs  of  degeneracy  may  be  mentioned  the  follow- 
ing: Certain  anomalies  of  cranial  development;  disproportion  of  the  bones  of 
the  face  and  the  bones  of  the  cranium;  lack  of  symmetry  in  the  development 
of  the  two  halves  of  the  face;  defective  position  and  abnormal  size  (too  large 
or  too  small)  of  the  ears;  immediate  transition  of  the  lobes  of  the  ears  into 
the  skin  of  the  cheek;  rudimentary  formation  of  the  ears;  incomplete  diflFer- 
entiation  of  the  teeth  and  absence  of  the  second  dentition;  too  large  or  too 
small  a  mouth;  harelip  and  wolf's  throat;  hypertrophy  of  the  under  lip; 
prominence  of  the  os  incisivvm;  a  palate  too  deep,  too  narrow,  too  flat,  or  too 
wide,  or  one-sided  flattening  of  it:  defective  union  of  the  palatal  suture; 
obliquity  of  the  nose  or  of  the  palpebral  fissures;    retinitis  pigmentosa,  con- 


130         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

genital  blindness,  coloboma  iridis,  and  albinism;  distorted  growth;  hypertro- 
phy of  the  subcutaneous  fatty  tissue;  club-foot  and  club-hand;  lack  of 
symmetry  of  the  hands;  epispadias  and  hypospadias;  absence  of  one  or  both 
testicles;  infantile  testicles;  hermapliroditism;  uterus  bicornis,  absence  of 
the  uterus,  vagina,  or  mamnia;;  abnormal  growth  of  hair  on  the  body;  beards 
in  women;  distorted  gi-owth  of  the  eyebrows,  etc.  The  relationship  between 
disturbances  of  development  of  tlie  brain  and  these  anatomic  signs  of  degen- 
eracy is  most  clearly  shown  in  crctini.sm. 

With  special  reference  to  anomalies  of  the  skull,  it  must  stUl  be  remem- 
bered that  the  brain  and  skull  are  independent  in  growth,  but  still  stand  in 
reciprocal  relation.  Thus  a  microcephalic  skull  may  be  due  to  premature 
synostosis  of  the  cranial  sutures,  but  it  may  also  result  trom  arrest  of  devel- 
opment of  the  brain  itself.  Premature  synostoses  of  the  cranial  sutures,  for 
the  most  part,  lead  to  partial  limitations  of  the  intracranial  space.  The  most 
striking  variety  of  this  anomaly  is  the  premature  tribasal  synostosis  that  lies 
at  the  foundation  of  cretinism.  The  anomalies  acquired  as  a  result  of  rickets 
are  to  be  diflFerentiated  from  these,  which  are  anomalies  of  development  that 
depend  upon  defects  in  the  embryo  itself  and  are  usually  hereditary. 

That  acquired  affections  of  the  brain  may  likewise  induce  secondary 
trophic  disturbances  has  been  proved  by  Charcot.  In  support  of  this  we  have 
the  acute  pernicious  decubitus  following  certain  focal  diseases  of  the  brain 
(apoplexy)  located  on  the  back  on  the  hemiplegic  side,  independent  of  any 
anesthesia,  vasomotor  paralysis,  and  ^vith  perfect  cleanliness;  also  the  inflam- 
mation of  the  synovial  membranes  of  the  joints  on  the  paralyzed  side,  in 
cerebral  cases,  brain  softening,  and  apoplectic  foci. 

In  mental  diseases  the  cerebral  trophic  influence  is  shown  by  remarkable 
variations  of  body-weight,  independent  of  food  and  manner  of  living:  e.g.,  the 
astounding  increase  of  fat  when  a  patient  passes  from  a  primary  to  the  sec- 
ondary stage  of  insanity;  also,  in  certain  cases,  the  severe  progressive  fatty 
degeneration  of  the  blood-forming  organs  that  occurs  without  cause,  and 
leads  rapidly  to  death  as  a  result  of  anomaly  of  blood-formation — the  so-called 
pernicious  anemia.  The  abnormal  brittleness  of  the  bones  of  certain  patients 
not  infrequently  accompanied  by  increased  excretion  of  phosphoric  acid  and 
calcium  carbonate  is  also  to  be  mentioned.  In  such  cases  the  bones,  especially 
the  ribs,  show  a  disappearance  of  the  inorganic  salts  and  become  soft.  Rind- 
fleisch calls  attention  to  the  possibility  that  hyperemic  stasis  in  the  vessels  of 
the  bone-marrow  may  be  the  cause  of  the  absorption  of  the  organic  salts,  and 
that  this  hyperemia  may  be  dependent  upon  anomalies  of  the  vasomotor 
nerves. 

In  melancholies  and  the  demented  certain  disturbances  of  nutrition  of  the 
skin  are  noteworthy  (zoster,  roughness  of  the  epidermis  and  nails),  Avhich  also 
occur  in  the  hysteropathic.  They  call  to  mind  analogous  processes  in  lepra 
mutilans,  the  cause  of  which  Virchow  found  to  be  a  perineuritis. 

Of  late,  interesting  cases  of  abnormal  pigmentation  in  the  insane  have 
been  published  ("nigrities"). 

Finally,  the  remarkable  rapidity  with  which  healing  of  injuries  takes 
place  in  the  first  stages  of  dementia  paralytica  is  to  be  mentioned,  probably 
due  to  paralysis  of  vessels  and  the  readiness  with  which  new  vessels  are 
formed,  while  in  the  later  stages  of  this  disease  (degeneration  of  the  posterior 
Jiorns  of  the  spinal  cord)  wounds  do  not  heal,  and  decubitus  readily  occurs. 


ELEMENTARY  ANOMALIES  OP  THE  CEREBRAL  FUNCTIONS.    131 

CHAPTER  XII. 
Disturbances  of  the  Secretory  Functions. 

Anomalies  of  this  kind  are  frequent  in  the  insane^  but  they  have 
been  but  little  investigated.  In  the  majority  of  such  cases  their  origin 
in  disturbances  of  the  circulation  following  alterations  of  vasomotor 
innervation  is  suggested;  in  some  cases,  in  abnormal  changes  affect- 
ing certain  centers  of  the  nervous  system  that  regulate  secretory 
processes. 

Disturbances  of  secretion  are  regularly  found  in  acute  states  of 
insanity,  but  they  may  be  vi^anting  in  chronic  insane  conditions.  In 
melancholic  insanity  the  secretions  are  usually  lessened,  while  in 
maniacal  states  they  are  usually  increased. 

Secbetion  of  Teaks. — A  fact  that  was  noticed  by  the  older  observers  is 
that  frequently  the  secretion  of  tears  is  wanting  in  melancholies.  "My  eyes 
are  as  dry  as  my  heart."  Usually  only  with  the  beginning  of  convalescence  is 
weeping  accompanied  by  tears. 

Ueinaey  Secretion. — Qualitative  and  quantitative  changes  in  the  secre- 
tion of  urine  are,  as  is  well  knoAvn,  not  infrequent  in  brain  diseases.  They  may 
be  (Mendel)  the  expression  of  anomalies  of  tissue-metabolism  in  the  brain;  of 
tissue-metabolism, 'induced  by  the  brain  disease,  in  other  organs;  or  they  may 
result  from  the  influence  of  the  diseased  brain  upon  the  vasomotor  nerves  of 
the  kidneys  (injuries  of  the  crura  and  consequent  apoplexies  in  the  kidneys 
and  "albuminuria) . 

Examination  of  the  urine  of  the  insane  is  of  great  importance  as  throw- 
ing light  upon  tissue-changes,  but  quantitative  examination  is  not  easy  to 
carry  out  on  accoimt  of  the  difficulty  of  collecting  the  entire  secretion. 

Rabow  finds,  partly  in  accord  with  Lombroso,  that  diuresis  is  lessened  in 
melancholia.  In  spite  of  abundant  exhibition  of  fluid  it  may  sink  to  100  cubic- 
centimeters.  We  have  no  reliable  statements  concerning  the  amount  of  urine 
secreted  in  conditions  of  mental  excitement. 

According  to  Lombroso,  the  specific  gravity  is  lessened  in  melancholia 
(according  to  Rabow,  the  opposite),  normal  in  mania,  and  increased  in 
dementia. 

As  bearing  upon  the  qualitative  relations  of  the  urine,  the  following  is 
noteworthy:  Rabow  found  decided  lessening  of  the  chlorides  and  urea  in  the 
melancholic.  Paralytics,  in  the  beginning  of  the  disease,  usually  secrete  a 
great  amount  of  urine,  and,  corresponding  with  the  increased  consumption  of 
nourishment,  more  urea  and  chlorides  than  healthy  indiAäduals.  With  in- 
creasing dementia  the  amount  of  urine  decreases,  with  absolute  diminution  of 
the  amount  of  urea  and  chlorides,  while  the  specific  gravity  is  increased,  and 
cloudiness  is  seldom  wanting  as  a  result  of  uric  acid  salts. 

In  the  extremest  degrees  of  secondary  dementia  Rabow  found  that  urea 
and  chlorides  did  not  correspond  with  the  gi-eat  amount  of  food  consumed, 
and  that  therefore  a  certain  retardation  of  tissue-metabolism  took  place. 


133         GENERAL  PATHOLOGY  AND  TUERArY  OF  INSANITY. 

Mendel  has  made  important  investigations  with  reference  to  pliosphoric 
acid.  He  found,  as  a  rule,  in  cases  of  chronic  brain  disease,  the  amount  of 
phosphoric  acid  absolutely  and  relatively,  as  compared  Avith  the  other  solid 
constituents,  less  than  in  the  healthy,  who  consumed  quantitatively  and  quali- 
tatively the  same  food. 

In  those  periods  of  paralysis  in  wliich,  in  spite  of  a  good  appetite  and  the 
absence  of  fever,  rapid  loss  of  body-weight  is  noticeable,  the  urine  was  unusu- 
ally heavy  (1.030),  and  pliosphoric  and  sulphuric  acids  were  markedly  increased 
relatively  to  the  other  solid  constituents. 

In  states  of  maniacal  excitement  tlicre  was  a  marked  decrease  of  phos- 
phoric acid  to  1  per  cent,  and  less,  absolutely  and  relatively  as  compared  with 
the  other  solid  constituents  of  the  urine.  After  apoplectiform,  epileptic,  and 
epileptiform  attacks,  phosphoric  acid  increases  absolutely  and  relatively. 

A  statement  of  Huppert,  to  the  effect  that  after  epileptic  attacks  albu- 
min appears  in  the  urine,  has  been  confirmed  by  Rabow  and  others. 

Too,  in  paralytics,  albumin  was  demonstrated  by  Rabenau  in  numerous 
cases;  and  the  fact,  demonstrated  by  Iluppert,  that  albumin,  in  connection 
with  hyaline  easts  and  red  blood-corpuscles,  appeared  after  cerebral  attacks 
(apoplectiform  and  epileptiform)  was  confirmed. 

Huppert  has  observed  the  same  thing  in  very  acute  mania,  in  epileptic 
attacks  due  to  lues,  in  senile  dementia  with  paralytic  attacks,  and  also  in  the 
early  stages  of  simple  apoplexy. 

West^hal  has  observed  albuminuria  in  delirium  tremens,  and  Fürstner 
has  seen  it  as  a  transitory  symptom,  usually  in  association  with  fibrin  casts 
and  a  few  blood-corpuscles,  in  chronic  alcoholism,  without  finding  nephritis  at 
the  autopsy.  ' 

Fiirstncr's  view,  that  this  transitory  albuminuria  is  brought  about  by  an 
affection  of  the  albumin  center  (Claude  Bernard)  due  to  disturbance  of  the 
circulation,  requires  further  confirmation. 

Anomalies  of  the  Secretion  of  Saliva. — In  melancholic  conditions 
the  secretion  of  saliva  is,  for  the  most  part,  diminished;  in  the  maniacal  it  is 
frequently  increased.  Tlie  increase  in  the  secretion  of  saliva  (ptyalism)  is 
not  to  be  confounded  with  simple  flowing  of  the  saliva  from  the  mouth  when 
there  is  paralysis  of  deglutition,  or  when  the  mouth  is  held  open,  and  the 
quantity  of  the  secretion  is  not  abnormal,  as  often  occurs  in  the  demented 
and  in  states  of  stupor. 

The  secretion  of  saliva  takes  place  under  the  influence  of  the  fifth,  the 
facial,  and  the  sympathetic  nerves.  The  real  secretory  nerve  is  the  chorda 
tympani.  After  section  of  this  nerve,  or  after  it  has  been  paralyzed  by 
atropin,  the  secretion  of  saliva  stops  completely,  although  the  amount  of  blood 
passing  to  the  gland  is  unaltered.  The  influence  of  the  sympathetic  is  vaso- 
motor; the  lingual  nerve  acts  reflexly  upon  the  facial  nerve  by  way  of  the 
maxillary  ganglion. 

Eckhardt  proved  that  irritation  of  the  fifth  and  the  facial  produces  a 
watery  saliva,  poor  in  organic  constituents;  while  irritation  of  the  sympa- 
thetic produces  saliva  quite  rich  in  organic  constituents,  thick,  and  ropy. 
These  experiments  are  confirmed  also  clinically,  for  states  of  irritation  of  the 
trigeminus  sometimes  are  attended  by  secretion  of  a  thin,  watery  saliva,  while 
in  excitation  of  the  sympathetic,  as  in  pregnancy,  sexual  and  gastro-intestinal 
diseases,  there  is  increased  secretion  of  a  thick  saliva. 


ELEMENTARY  ANOMALIES  OF  THE  CEEEBRAL  FUNCTIONS.    13  3 

Stark  has  reported  cases  of  insanity  which  so  far  correspondofi  with  the 
physiologic  experiment,  that  a  thin,  watery  /low  of  saliva  was  simultaneous 
with  exacerbations  of  a  neuralgia  of  the  fifth  nerve;  a  thick  saliva  accom- 
panied states  of  sexual  irritation;  so  that  the  quality  of  the  saliva  is  an  indi- 
cation, in  some  cases,  of  the  idiopathic  or  sympathetic  significance  of  the 
disease-picture. 

Investigations  by  Owsjannikow,  Lepine,  Bacchi,  and  Bochefontaine,  ac- 
cording to  which  irritation  of  certain  parts  of  the  cortex  of  the  cerebral 
hemisphere  increased  the  secretion  of  saliva,  require  still  further  confirmation. 
However,  they  explain  the  frequency  of  an  increased  flow  of  saliva  in  certain 
affections  of  the  forebrain   (psychoses). 

Menstruation. — Disturbances  of  this  function  are  frequent  in  insanity. 
They  are  the  expression  of  constitutional  (anemia)  or  local  disturbances  of 
nutrition,  or  of  disturbances  of  vasomotor  innervation,  that  may  stand  in 
genetic  relation  with  the  causal  moment  of  the  psychosis  or  the  fundamental 
pathologic  process  in  the  brain. 

While  in  the  secondary  stages  of  insanity,  aside  from  local  or  general 
diseases,  disturbances  of  menstruation  are  regularly  wanting,  anomalies  of 
this  kind  are  very  frequent  in  the  primary  stages  of  insanity.  As  a  rule,  in 
such  cases,  there  is  a  temporary  or  lasting  amenorrhea;  and,  in  case  it  be 
lasting,  the  return  of  the  menses  usually  takes  place  only  with  restoration  of 
physical  health.  Sometimes  amenorrhea  continues  a  long  time  after  the  estab- 
lishment of  convalescence.  In  some  few  cases  where  sudden  suppression  of  the 
menses  has  coincided  with  the  outbreak  of  a  psychosis  the  return  of  the 
menses  may  be  devoid  of  critical  sig-nificance;  for  both  may  be  the  effects  of 
the  same  cause,  and  the  suppression  of  the  menses  not  the  cause  of  the 
psychosis. 


CHAPTER   Xni. 
Disturbances  in  the  Domain  of  the  Vital  Functions. 

Temperatüre. — On  the  whole^  it  may  be  said  that  the  psj^clioses 
are  afebrile  brain  diseases;  still,  not  infrequently  they  present  devia- 
tions of  temperature  from  that  usual  in  the  healthy,  and  a  deviation 
may  be  either  an  increase  or  decrease. 

Late  investigations  by  Eulenburg  and  Landois  demonstrate  the  influence 
of  superficial  destruction  of  certain  cortical  areas  (anterior  central  convolu- 
tion, anterior  extremity  of  the  gyrus  fornicatus)  upon  the  temperature,  and 
suggest  that  in  affections  of  the  cortex  (psychoses),  alterations  of  tempera- 
ture are  quite  possible.  In  general,  superficial  injuries  of  the  cortex,  as  well 
as  strong  faradic  irritation  of  the  parts  mentioned,  induce  elevation  of  tem- 
perature on  the  opposite  side  of  the  body  (Eulenburg,  Hitzig),  while  weak 
faradic  stimulation  of  the  areas  causes  lowering  of  the  temperature. 

Ripping  observed  increase  of  temperature  on  the  opposite  side  of  the 
body  in  a  case  of  sarcoma  affecting  the  posterior  part  of  the  gyrus  fornicatus; 
also  differences  of  the  temperature  of  the  two  sides  of  the  body  as  great  as 
0.9°  C.  in  mania,  melancholia,  melancholia  with  stupor,  and  dementia  para- 


134    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

lyticii,  simultaneous  with  other  neurotic  syniptunis  (ptyalisiii,  unequal  pupils, 
unilateral  sweating,  facial  paralysis). 

Increased  temperature,  with  exclusion  of  complicating  diseases  of  the 
vegetative  organs,  may  depend  on  irritative  processes  in  certain  areas  of  the 
cortex.  Tliis  is  observed  in  congestive,  paralytic,  aijd  epileptic  attacks;  in 
acute  dtliriuin  and  delirium  tremens;  in  the  status  epilepticus,  and  the  agony 
of  the  insane.  In  constitutionally  neuropathic  and  other  very  weak  patients 
constipation  or  retention  of  urine  may  induce  a  rise  of  temperature  to  40°  C., 
without  causing  any  disturbance  of  general  feeling,  and  the  thermometei 
alone  discloses  the  trouble.  More  frequently  subnormal  temperature  is  ob- 
served in  the  insane.  For  the  most  part,  this  is  due  to  increased  loss  of  heat 
(naked,  raving  patients;  paralytics  with  general  paralysis  of  the  vascular  sys- 
tem). In  many  patients  (melancholia  with  stupor  and  the  passive  form), 
where  all  loss  of  heat  is  prevented  by  keeping  them  in  bed  and  well  covered, 
subnormal  temperatures  as  low  as  36°  C.  are  still  observed,  which  can  be  ex- 
plained only  by  lesstened  production  of  heat,  decreased  tissue-metabolism,  and 
incomjilete  respiration. 

Too,  in  the  maniacal  tlie  increased  loss  of  heat  usually  overcomes  the 
increased  production  of  heat  resulting  from  excessive  muscular  activity. 

True  collapse  temperatures  as  low  as  23°  C.  have  been  observed  by  Lowen- 
hardt  and  Zenker  a  long  time  before  death  in  cases  of  mania  leading  to 
exhaustion.  In  these  cases  the  patients  had  feelings  of  euphoria  and  an 
excellent  appetite.  I  have  made  similar  observations  in  cases  of  paralytics 
some  days  before  death,  who  were  in  bed  and  well  covered  and  with  tempera- 
tures in  the  rectum  as  low  as  24°  C. 

Pulse. — The  qualitative  anomalies  of  the  pulse  were  mentioned 
in  connection  with  vasomotor  disturbances.  The  frequency  of  the 
pulse  is  very  changeable.  Great  frequency  is  sometimes  observed  in 
states  of  excitement,  especially  in  cases  of  fear,  and  is  here  referable 
to  the  psychic  excitement.  The  increase  of  the  heart's  action  in 
the  maniacal  is  often  remarkably  slight,  in  spite  of  the  great  unrest 
and  jactitation  of  the  patients.  It  may  even  happen  in  these  cases 
that  the  pulse  is  lowered  to  40  beats — probably  to  be  explained  by 
abnormal  irritation  in  the  path  of  the  vagus,  and  sometimes  as  due 
to  states  of  profound  inanition. 

DiGESTiOiSr  AND  ASSIMILATION". — Digestion  and  assimilation  are 
frequently  disturbed  in  the  acute  and  primär}^  states  of  insanity.  Dis- 
turbances of  these  functions  are  not  infrequent  causes  of  the  disease; 
more  frequently  they  are  complications  (ride  supra),  and  sometimes 
the  results  of  fasting. 

Eespiration. — Disturbances  of  respiration  are  most  common  in 
melancholia. 

They  may  be  due  to  precordial  anxiety  and  neuralgias.  The 
respiration  is  then  superficial  and  insufficient.  Tuberculosis  of  the 
lungs  often  develops  as  a  result  of  insufficient  respiration. 


ELEMENTARY  ANOMALIES  OF  THE  CEREBRAL  FUNCTIONS.    135 

Peculiar  intermittent  and  remittent  and  arhythmic  respiration, 
resembling  the  Cheyne-Stokes  phenomenon,  has  been  observed  by 
Zenker  in  connection  with  cerebral  attacks. 

Genekal  NuTRTTiOiNr.  lioDY-WEiGiiT. — The  relations  of  metab- 
olism and  general  nutrition  in  the  insane  are  of  great  importance, 
the  approximate  measure  of  which  is  the  body-woiglit. 

Investigations  of  this  kind  Justify  the  conclusion  that  the  graver 
disturbances  of  general  tissue-metabolism  go  hand  in  hand  with  psychic 
diseases,  and  that  the  majority  of  psychoses  are  nothing  more  than  an 
expression  of  profound  disturbances  of  nutrition  in  which  the  brain  is 
involved,  and  in  which  a  predisposition  of  this  organ,  as  locus  minoris 
resistentice,  places  disturbances  of  the  psychic  functions  in  the  fore- 
ground of  the  disease-picture. 

By  the  investigations  made  by  Albers,  Nasse,  Lombroso,  Stiff,  and 
others,  it  is  shown  that  in  melancholies  and  maniacs  an  increasing 
loss  of  weight  accompanies  the  psychic  disease-processes  at  their 
height;  that,  in  general,  remissions  are  accompanied  by  increase  of 
weight,  exacerbations  with  loss  of  weight;  and  that  with  the  occur- 
rence of  convalescence  -there  is  usually  a  rapid  increase  of  weight.  In 
some  cases  the  increase  of  weight  was  as  much  as  one-half  pound  or 
more  daily.  The  absolute  increase  Nasse  reckoned  on  an  average  as 
21.6  per  cent,  in  insane  females,  and  15.8  per  cent,  in  males. 

If  primary  psychoses  pass  over  into  secondary  states  of  mental 
weakness  the  usual  weight  is  regained  and  remains  quite  stationary. 

Increase  of  weight  in  cases  which  result  so  unfavorably  is  not  con- 
stant. In  cases  where  it  occurred  it  was  steadier  and  slower  than  in 
cases  that  progressed  to  recovery.  Too,  in  periodic  insanity  paroxysms 
and  loss  of  body-weight  occur  simultaneously,  and  the  two  progress 
together.  Improvement  takes  place  with  the  beginning  of  increase 
of  weight. 

The  great  significance  of  increase  of  body-weight  (as  much  as 
twenty-nine  kilograms)  in  recovery  from  puerperal  insanity  has  been 
emphasized  by  Eipping. 

Sleep. — Disturbances  of  sleep  are  frequent  in  the  insane,  and 
almost  constant  in  the  primary  stages  of  insanity.  In  melancholia 
and  mania  sleep  may  be  absent  for  weeks  at  a  time.  In  melancholies 
sleep  is  not  refreshing,  and  the  patient  then  thinks  that  he  has  not 
slept  or  compares  his  sleep  with  that  induced  by  narcotics. 

In  the  secondary  stages  of  insanity  sleep  is  usually  normal,  unless 
disturbed  by  intercurrent  states  of  excitement,  especially  by  hallucina- 
tions. In  profound  dementia  and  brain  exhaustion  after  mania,  sleep 
is  often  unusually  long  and  deep. 


PART  SECOND. 
The  Causes  of  Insanity, 


The  discovery  of  tlie  causes  of  insanity  is  one  of  llio  most  ini])or- 
tant  tasks  that  confront  scientific  investigation.  Tlie  study  of  tliein 
leads  the  way  to  pathog-enesis  and  prophyhixis. 

An  evil  like  insanity,  affecting  seriously  both  the  individual  and 
society,  early  led  to  investigation  of  the  conditions  that  give  rise  to  it. 
The  following  exposition  of  our  present  knowledge  of  its  etiology  will 
show  that  investigations  in  this  direction  have  not  been  without  fruit- 
ful results;  indeed,  the  etiology  of  insanity  is  even  better  known  than 
that  of  most  other  diseases,  in  spite  of  the  fact  that  in  this  domain 
we  have  very  great  difficulties  with  which  to  contend. 

The  difficulties  are,  in  the  first  place,  due  to  the  fact  that,  as  a  rule,  a 
number  of  causal  factors  work  together  to  induce  the  resultant  insanity.  To 
determine  each  one  of  these  factors,  and  especially  the  value  of  each,  is 
scarcely  possible,  owing  to  the  lack  of  clearness  of  knowledge  concerning 
pathogenesis. 

With  respect  to  a  number  of  causal  factors  that  are  general  in  their 
effect,  the  aid  given  by  statistics  cannot  be  dispensed  with.  They  are  of  great 
aid  in  etiologic  investigation,  but  only  when  the  question  is  correctly  and 
precisely  stated  and  there  is  careful  and  unprejudiced  use  of  the  raw  material 
of  statistics.  Moreover,  statistics  never  giv«  the  cause  of  a  phenomenon,  but 
only  show  the  direction  in  which  the  cause  is  to  be  sought  (Hagen).  The 
figures  obtained  must  be  correctly  interpreted. 

For  example,  from  the  statistic  fact  of  the  greater  number  of  female 
patients  in  insane  asylums  it  is  not  to  be  concluded  that  the  female  sex  ex- 
hibits a  greater  morbidity  than  the  male.  The  principal  cause  lies  rather  in 
the  lesser  mortality  of  the  female  insane. 

Only  too  frequently  does  it  happen  that  the  laity  and  inexperienced 
physicians  regard  the  last  and  striking  link  in  the  chain  of  causes  as  the  only 
cause,  and  thus  ignore  the  effect  of  all  previous  and  less  prominent  influ- 
ences. Loss  of  business,  emotions,  and  the  like  are  looked  upon  as  causes, 
when  actually  scientific  investigation  shows  that  hereditary  and  weakening 
diseases  were  the  true  etiologic  factors  upon  which  the  former  acted,  and  thus 
were  effective  in  bringing  about  the  catastrophy. 

Only  too  frequently  does  it  happen  that  results  or  symptoms  of  mental 
disturbance  are  mistaken  by  the  friends  for  the  cause  of  the  disease.    A  busi- 

(ic;;) 


THE  CAUSES  OF  INSANITY.  137 

ress  man  in  tlie  initial  stages  of  paralysis  makos  unfortunate  speculations. 
Then  the  origin  of  the  disease,  which  soon  becomes  manifest  to  the  laity, 
is  ascribed  to  bad  speculations,  while  scientific  investigation  of  the  case  proves 
that  the  individual  made  bad  speculations  because  his  brain  was  diseased. 

A  maniac  may  be  said  to  have  become  insane  because  of  excesses  in 
alcohol;  exact  investigation  shows  that  this  individual  indulged  in  these 
excesses  because  he  was  suffering  with  maniacal  exaltation. 

A  peasant's  wife  returns  home  from  a  religious  meeting  and  becomes 
maniacal;  it  is  thought  then  that  religion  made  her  insane.  In  reality,  al- 
ready insane  and  melancholic,  she  went  there  to  find  forgiveness  for  heV-  sup- 
posed sins. 

The  mistaking  of  the  symptoms  or  the  results  of  disease  for  causes  is 
an  everyday  event  in  the  observation  of  alienists,  and  therefore  warns  him  to 
accept  the  statements  of  the  laity  with  great  circumspection. 

The  history  must  take  into  consideration  the  general  mental  and  physical 
individuality,  for  often  mental  disturbances  are  only  final  results  of  all  pre- 
vious states  of  life  and  development.  For  we  have  here  to  deal  not  with  dis- 
ease that  may  be  precisely  described  anatomically,  but  with  the  abnormal 
individual  (Schule).  The  exact  physical  and  mental  condition  of  the  patient; 
the  habitual  state  of  health;  any  possible  abnormal  dispositions  and  previous 
diseases;  the  original  disposition;  the  development  under  education;  the 
inclinations,  tendencies,  and  circumstances  of  life  of  the  individual;  the  form 
of  reaction  to  external  influences  and  injuries — all  these  must  be  carefully  in- 
vestigated before  we  can  think  of  determining  what  the  etiology  is  in  the 
concrete  case. 

As  a  rule,  however,  it  is  not  sufficient  to  know  the  individual  history  of 
life  and  development;  usually  we  must  go  further  to  the  physical  and  mental 
peculiarities  of  progenitors,  for,  with  the  exception  of  tuberculosis,  there  is  no 
disease  that  is  so  far  grounded  in  heredity,  in  physical  and  mental  anomalies 
of  organization,  and  in  the  life  and  conditions  of  progenitors,  as  insanity. 

Unfortunately  with  reference  to  this  important  etiologic  qviestion,  the 
answer  is  only  too  frequently  unsatisfactory,  since  often  we  have  to  deal  with 
persons  born  out  of  wedlock,  with  those  of  the  lowest  classes  who  know 
nothing  of  their  ancestors,  or  with  individuals  of  the  higher  classes  of  society 
that  conceal  unfortunate  hereditary  circimistances. 

Finally,  exact  statistics  must  consider  that  the  juridic  sentence  is  not 
always  applicable  in  natural  science:    "Pater  est  quern  miptice  demonstrant!" 

The  etiology  of  mental  disease  is  essentially  that  of  other  cerebral 
and  nervous  diseases,  and  therefore  they  belong  to  the  same  pathologic 
family.  A  superficial  consideration  of  the  causal  elements  divides 
them  into  two  large  groups: — predisposing,  or,  more  correctly,  expos- 
ing; and  accessory — i.e.,  exciting  and  often  accidental.  A  sharp  dis- 
tinction of  these  two  classes  in  the  concrete  case,  however,  is  not  always 
possible,  since  a  predisposing  cause  (hereditarily  abnormal  brain  or- 
ganization, improper  training)  may  also  be  at  the  same  time  the 
exciting  cause,  in  that  it  leads  to  affects,  passions,  and  perverse  manner 
of  life,  which  cause  the  ultimate  outbreak  of  insanity. 


138    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

In  general,  experience  teaches  that  predisposing  influences  are  of 
much  greater  importance  than  accidental  causes,  and  are  of  themselves 
sufficient  to  induce  insanity. 

In  the  class  of  predisposing  causes  there  are  again  general  factors 
to  which  a  certain  statistic  and  minimal  value,  in  their  influence  on 
the  individual,  must  he  given,  and  certain  purely  individual  influ- 
ences depending  upon  the  physical  and  mental  disposition  of  the 
patient  and  his  circumstances  of  life,  the  significance  of  which  is  very 
much  greater  than  that  of  the  general  factors. 

Accessory  or  accidental  causes  are  usuall}^  divided  into  physical 
and  moral :  a  distinction  which  has  hut  a  superficial  value  for  classifi- 
cation, and  is  only  justified  when  it  recognizes  that  every  moral  cause 
is  physically  efl'ectual,  whether  through  an  organically  founded  predis- 
position, as  a  result  of  which  it  operates  effectually  as  shock;  or 
whether  it  operates  directly  to  disturb  the  nutrition  of  the  brain  and 
thus  induce  the  psychosis  by  its  effect  upon  the  vasomotor  innervation, 
or  indirectly  by  way  of  disturbances  of  the  processes  of  general 
nutrition. 

Predisposing  Causes. 

1.  General  Peedisposing  Causes. 
Civilization. 

A  phenomenon  that  seems  to  be  proved  by  the  statistics  of  almost 
all  nations  and  asylums  is  the  increasing  frequency  of  insanity  in 
modern  times. 

Medical  science  asks : — 

(a)  Is  this  increase  of  mental  diseases  actual  or  only  apparent?     And,  in 
case  this  is  answered  in  the  affirmative, 
(ij  By  what  factors  is  it  induced? 

(a)  With  reference  to  the  first  question  it  must  be  taken  into  con- 
sideration that  exact  figures  for  the  comparison  of  more  ancient  times 
with  later  periods  are  wanting;  that  the  statistics  of  insanity  and 
the  number  of  insane  of  earlier  decades  leave  much  to  be  desired  as 
far  as  exactness  is  concerned,  while  to-day  the  improvement  in  diagno- 
sis and  greater  care  of  the  insane  bring  more  patients  under  observa- 
tion; further,  that  the  careful  management  of  patients  in  asylums 
prolongs  life,  and  therefore  they  increase  in  number  there;  finally, 
that  the  general  population  has  much  increased.  But  all  these  sources 
of  error  are  not  sufficient  to  explain  the  fact  that  in  all  civilized  coun- 
tries the  number  of  insane  has  almost  doubled :  in  England,  for  exam- 


tHE  CAUSES  OF  INSANITY.  130 

pie,  from  14,500  in  1849  to  30,000  in  18GÜ.  This  drives  us  to  conclude 
that  actually  there  has  been  an  increase;  and,  if  this  increase  has  not 
been  as  great  as  it  seems,  still  it  has  been  sufficient 'to  cause  appre- 
hension. 

(b)  Increasing  civilization  has  been  held  responsible  for  this 
augmentation;  and  it  has  been  pointed  out  that,  among  uncivilized  or 
half -civilized  peoples,  insanity  is  a  very  infrequent  phenomena,  while 
actually  there  is  at  least  one  insane  person  to  every  five  hundred  sane 
in  the  highly  civilized  nations. 

An  attempt  has  been  made  to  explain  the  relative  immunity  to 
insanity  of  uncivilized  people  by  circumstances  of  life  in  which  there 
are  no  political  or  religious  storms  and  no  refined  pleasures  of  life, 
but  a  simple  and  more  natural  method  of  living ;  but  all  these  factors 
are  in  themselves  of  little  value  as  long  as  parallel  statistics  of  insan- 
ity among  uncivilized  and  civilized  peoples  are  wanting,  and  our 
knowledge  of  insanity  among  the  uncivilized  is  confined  to  occasional 
mention  in  books  of  travel  by  naturalists  and  missionaries.  Certainly 
estimates  of  the  number  of  the  insane,  which  make  but  an  accidental 
impression  upon  the  laity,  are  not  the  figures  of  the  expert,  and  con- 
sequently they  are  doubtless  much  below  the  actual  number.  Accord- 
ing to  the  testimony  of  Griesinger,  many  insane  patients  go  about  in 
the  Orient  as  saints  and  beggars. 

But,  even  when  we  allow  the  fact  of  the  increase  of  insanity  in 
modern  society  to  be  dependent  upon  factors  that  are  included  in  the 
word  civilization,  we  are  still  forced  to  resolve  this  factor  into  its  ele- 
ments, and  to  bring  up  a  number  of  etiologic  questions,  the  answers 
to  which  are  difficult  and  possible  only  with  the  help  of  careful  and 
extensive  statistics. 

Unquestionably  some  of  the  conditions  of  increasing  civilization  axe 
really  unfavorable  to  the  origin  of  insanity. 

Among  these  are  to  be  mentioned  better  food,  dress,  and  housing,  educa- 
tion of  the  people  religiously  and  intellectually,  finer  cultivation  and  greater 
morality. 

But  along  with  these  regenerating  influences  there  are  other  immediate 
outgrowths  of  civilization  that  are  dangerous,  owing  to  their  eifect  to  favor 
the  occurrence  of  insanity. 

Among  these  are  the  enormous  growth  of  population  of  great  cities, 
with  the  resultant  evil  influences,  hygienically  (tuberculosis,  scrofula,  anemia) 
and  morally;  the  increase  of  a  meaitally  and  physically  degenerate  proleta- 
riat; pauperism;  predominating  factory  life;  lack  of  marriage;  the  increasing 
intellectual  and  morally  destructive  craze  for  riches  and  luxury. 

But  all  these  factors  are  surpassed  by  the  circumstance  that  increasing 
civilization  creates  refined  and  complicated  conditions  of  life,  and  thus  leads  to 
greater  struggle  for  existence. 


140    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

This  strugylc  for  a  more  comfortable  and  therefore  more  exacting  exist- 
ence must  be  carried  on  by  the  brain. 

In  this  struggle  the  brain  becomes  finer  in  its  organization,  and  there- 
fore more  creative;  at  the  same  time  it  becomes  more  vulnerable  and  is  more 
reactive  to  stimuli  which  only  too  easily  lead  to  overstimulation,  with  con- 
sequent exhaustion,  disease,  and  degeneracy.  When  an  organ  is  forced  to 
increased  functional  activity,  it  is  more  readily  diseased,  is  more  easily  ex- 
hausted, and  strain  upon  it  is  onlj'  too  easily  changed  to  overstrain.  These 
increased  demands  of  the  struggle  for  existence  exercise  their  efi'ects  to-day 
upon  the  brain  of  the  individual  even  at  the  desk  in  school,  and  the  concur- 
rence of  all  these  influences  in  the  domains  of  art,  science,  and  industry,  with 
the  desire  for  luxury  and  riches,  keeps  a  great  part  of  modern  society  in  a  con- 
dition of  constant  nervous  strain  and  excitement. 

Another  important  factor  which  rims  parallel  with  the  increased  use  of 
nervous  force  is  the  need  of  certain  stimulants  that  have  an  influence  to  in- 
crease brain  activity  artificially. 

The  increasing  use  of  cofl'ce,  tea,  tobacco,  and  alcohol  is  certainly  no  acci- 
dental phenomenon,  but  more  or  less  a  measure  of  the  increased  work  which 
the  brain  must  do  to-day;  even  though  some  degree  of  health  is  compatible 
with  indulgence  in  such  stimulants,  it  is  not  possible  with  over-indulgence  in 
them.  Of  all  such  stimulants,  the  most  important  and  the  one  most  fre- 
quently used  to  excess,  and,  therefore,  the  most  dangerous,  is  alcohol.  In  the 
struggle  of  civilization  with  the  Indians  of  America,  as  fire-water  it  has  been  a 
more  powerful  means  of  subjugation  than  even  the  weapons  of  war.  It  is 
true  that  our  forefathers  perhaps  drank  a  greater  quantity  of  alcoholic  bev- 
erages than  we  do,  bxit  they  drank  wine  containing  a  smaller  percentage  of 
alcohol.  To-day  alcohol  is  found  in  more  concentrated  form,  and  it  has  been 
made  cheaper  and  therefore  Avithin  the  reach  of  everybody.  But  the  alcohol 
within  the  reach  of  the  lower  classes  is  the  poorest  sort,  usually  containing 
fusel  oil,  one  of  the  most  injurious  sTibstances  in  its  eft'ect  upon  the  central 
nervous  system.^ 

In  this  fact  alone  lies  a  factor  wiiich  easily  outweighs  all  that  civilization 
is  doing  for  the  prevention  of  insanity. 

All  exj^erience  shows  Avitli  great  probability  that  insanity  is  a  phe- 
nomenon constantly  increasing  in  frequency  in  modern  society,  and 
that  it  arises  from  overstimulation  of  the  brain  as  a  result  of  over- 
exertion and  intemperate  use  of  stimulants. 

These  injurious  influences  show  themselves  immediately  in  the 
predominance  of  the  neuropathic  constitution  in  modern  society, 
"which  has  too  many  nerves,  but  too  little  nerve."  This  neuropathic 
constitution  forms  the  most  important  predisposition,  not  only  for  in- 
sanity, but  for  all  possible  neuroses.     It  is  partly  acquired  as  a  result 


^  The  enormous  difi'erence  in  the  effect  of  ethyl  and  amyl  alcohol  is  best 
studied  in  their  nitrites.  Ethyl  nitrite  is  a  weak,  spirituous  fluid  the  fumes  of 
which  scarcely  affect  the  vascular  system,  while  amyl  nitrite,  even  in  the 
smallest  doses,  induces  complete  paralysis  in  the  carotid  system  of  vessels. 


THE  CAUSES  OF  INSANITY.  141 

of  some  perverse  mannor  of  life  in  tlie  individual,  partly  congenital 

and  due  to  the  inaiiJicr  of  lifo  of  |)rogcnitorö. 

The  influence  of  the  political  upheavals  and  religions  excitement  in 
modern  social  life  is  relatively  small.  Of  like  importance  are  other  accidents 
that  affect  populations  at  large  (earthquakes,  hunger,  financial  catastrophies, 
fires,  etc.).  As  a  result  of  such  accidents  those  individuals  first  succumb 
mentally  who,  on  account  of  their  predisposition,  are  not  able  to  withstand 
the  disturbing,  depressing  effects  of  fear  for  their  lives  or  for  the  lives  of  rela- 
tives; they  are  not  equal  to  enduring  the  fright  and  excitement  of  war,  the 
want  of  food,  and  other  deprivations  resulting  from  lack  of  employment. 

The  leaders  of  revolutions  become  insane  with  relative  frequency.  This 
was  shown  diu'ing  the  Commune  in  Paris.  The  explanation  of  this  is  that 
frequently  those  hereditarily  predisposed  and  eccentric  take  a  prominent  place 
at  the  head  of  such  movements. 


Nationality,  CUmatej  and  Seasons. 

These  factors  are  also  complicated.  In  particular,  the  idea  of 
nationality  includes  in  itself  race,  manner  of  life,  employment,  gov- 
ernment, religion,  and  the  various  degrees  of  civilization  and  morality. 

Moreover,  the  statistics  of  insanity  of  various  countries  are  not 
of  uniform  exactness  nor  gathered  from  the  same  standpoint,  and 
therefore  they  are  not  scientifically  satisfactory.  Still,  on  the  whole, 
the  percentage  of  the  insane  among  the  various  civilized  peoples  does 
not  vary  strikingly ;  and  the  same  holds  true  of  peoples  inhabiting  the 
warmer  and  colder  zones. 

Any  tendency  to  frequency  of  insanity  in  the  Avarmer  climates  is 
compensated  for  among  dwellers  in  more  northern  lands  by  the  con- 
sumption of  alcohol.  In  many  countries  where  miasmatic  and  telluric 
influences  are  effectual  and  lead  to  cretinism,  there  are  not  only  more 
insane,  but  a  larger  fraction  of  the  population  is  afflicted  with  psychic 
(dementia)  and  physical  defects  (goiter).  Too,  the  influence  of  insuf- 
ficient and  imperfect  food  makes  itself  apparent,  aside  from  the 
increase  of  scrofula,  rickets,  tuberculosis,  and  pellagra  (most  frequent 
among  the  peasants  of  northern  Italy,  who  live  on  corn),  in  constitu- 
tional anemia  and  neuropathic  and  psychopathic  conditions  dependent 
upon  them. 

It  has  been  quite  generally  supposed  that  summer  predisposes 
more  to  insanity  than  the  cooler  seasons.  It  is  a  fact  that,  in  countries 
where  the  population  is  largely  engaged  in  rural  pursuits,  the  num- 
ber of  patients  admitted  to  asylums  during  the  summer  months  is 
greater,  but  the  majority  of  these  patients  are  those  that  have  been  long 
diseased,  whom  during  the  winter  months  the  relatives  are  able  to 


143         GENERAL  PATHOLOGY  AND  TPTERAPY  OF  INSANITY. 

take  care  of  without  much  trouble,  Avhile  in  the  summer,  owing  to 
increase  of  work,  they  are  compelled  to  send  them  to  the  asylum. 

In  our  temperate  climate  the  heat  of  summer  has  nothing  more 
than  a  bad  effect  upon  patients  that  are  already  alllicted,  and  seldom 
causes  mental  disease  directly. 

Sex. 

Older  investigators,  like  Esquirol,  Haslam,  and  others,  supposed 
that  there  was  a  greater  disposition  to  insanity  in  females  than  in 
males. 

The  dangerous  periods  of  pregnancy,  childbirth,  and  tlic  climac- 
teric; the  fact  tliat  physically  and  mentally  woman  has  less  resistive 
power  than  man;  and,  further,  the  fact  that  insanity  is  inherited 
more  frequently  by  female  descendants,  seem  a  priori  to  favor  this 
assumption. 

These  fruitful  causes  of  insanity  in  the  female  sex,  however,  are 
amply  outweighed  in  the  male  sex  by  over-exertion  in  the  struggle  for 
existence,  since,  for  the  most  part,  man  must  carry  on  the  struggle 
alone;  and  drunkenness  and  sexual  excesses  are  much  more  disastrous 
in  their  influence  on  men  than  upon  women.  If  women  be  forced  to 
carry  on  the  struggle  of  life  alone,  as  is  the  case  with  many  widows, 
they  then  succumb  much  more  quickly  and  easily  than  men. 

Tlie  source  of  insanity  in  woman  that  should  not  be  underestimated  iä 
her  social  position.  Woman,  who,  owing  to  her  nature,  has  many  more 
sexual  needs  than  man,  at  least  in  the  ideal  sense,  Jinows  no  other  honorable 
gratification  of  them  than  marriage  (Maudsley). 

This  offers  her  also  the  only  means  of  protection.  Through  unnumbered 
generations  her  character  has  been  developed  in  this  direction.  Even  the  little 
girl  plays  "mother"  with  her  dolls.  Modem  life,  with  its  increased  demands, 
offers  constantly  less  prospect  of  satisfaction  in  marriage.  This  is  especially 
true  for  those  of  the  higher  classes,  where  marriages  are  consummated  later 
and  less  frequently. 

While  man  as  the  stronger,  owing  to  his  greater  intellectual  and  physical 
strength  and  his  free  social  position,  finds  sexual  gratification  without  trouble, 
or  an  equivalent  in  some  occupation  in  which  all  his  force  is  demanded,  these 
possibilities  are  denied  to  women  of  the  better  classes.  This  leads  consciously 
or  unconsciously  to  dissatisfaction  with  self  and  the  world  and  to  abnormal 
complaints.  For  a  long  time  in  many  cases  a  substitvite  is  sought  in  religion, 
but  in  vain.  Out  of  religious  enthusiasm,  with  or  without  onanism,  is  devel- 
oped a  host  of  nervous  complaints,  among  which  hysteria  and  insanity  are  not 
infrequent. 

It  is  only  by  this  fact  that  we  can  understand  the  great  frequency  of 
insanity  in  single  women  from  25  to  35  years  of  age, — i.e.,  at  the  period  when 
bloom  and  hope  disappear, — while  in  men  insanity  is  most  frequent  from  35 
to  50,  the  period  of  greatest  strain  in  the  struggle  for  existence. 


THE  CAUSES  OF  INSANITY.  143 

The  statistics  of  asylums  largely  show  the  predominanoe  of  female  in- 
mates. One  reason  for  this  has  already  been  alluded  to  in  the  le.sser  mortality 
among  them,  owing  to  the  infrequency  in  them  of  idiopathic  disease  like  de- 
mentia paralytica.  Another  cause  lies  in  the  fact  that  insanity  in  females  is, 
in  general,  clinically  more  turbulent  and  indecent  in  form  than  in  man,  and 
therefore  it  necessitates  more  frequent  commitment  to  an  asylum.  Too,  the 
circumstance  that  the  female  population  is  somewhat  greater  than  the  male 
is  to  be  taken  into  consideration. 

On  the  whole,  statistics  show  that  the  frequency  of  insanity  in 
both  sexes  is  about  the  same ;  that,  if  anything,  it  is  slightly  greater  in 
the  male  sex,  owing  to  drunkenness  and  greater  demands  upon  cere- 
bral activity. 

Creeds. 

Statistics  have  been  collected  with  great  care  to  show  the  per- 
centage of  insanity  in  the  various  religious  sects,  and  it  has  been 
shown  that  among  the  Jews  and  certain  sects  the  percentage  is  decid- 
edly higher.  This  fact  stands  in  relation  with  religion  only  in  so  far 
as  it  constitutes  a  hindrance  to  marriage  among  those  professing  it; 
the  more  when  its  adherents  are  small  in  number,  and  there  is  conse- 
quent insufficient  crossing  of  the  race  and  increased  inbreeding. 

This  is  a  phenomenon  similar  to  that  observed  in  certain  highly 
aristocratic  and  wealthy  families,  whose  members,  either  from  motives 
of  honor  or  money,  constantly  intermarry,  and  thus  have  many  insane 
relatives.    In  such  cases  the  cause  is  not  moral,  but  anthropologic. 

On  the  whole,  it  may  be  assumed  that  true  religion  and  pure 
ethics,  in  that  they  elevate  the  mind  of  man,  direct  it  to  higher 
aspirations,  and  offer  comfort  in  misfortune,  lessen  the  danger  of 
insanity. 

But  it  is  otherwise  when  the  religious  inclination  finds  expres- 
sion in  enthusiastic,  mystic,  or  zealous  activity,  behind  which  low 
passions  are  concealed. 

Even  under  such  circumstances,  it  requires  a  very  strong  pre- 
disposition in  order  to  make  the  factor  in  question  an  exciting  cause. 
Many  of  those  Avho  lose  their  heads  in  the  confessional  or  in  mission 
work  are  melancholic,  weak-minded  persons.  Many  of  those  who  seek 
protection  and  comfort  in  the  haven  of  religion  are  storm-tossed 
wrecks  on  the  sea  of  life,  physically  and  morally  broken. 

Very  often  excessive  religious  inclination  is  itself  a  symptom  of  an 
originally  abnormal  character  or  actual  disease,  and,  not  infrequently, 
concealed  under  a  veil  of  religious  enthusiasm  there  is  abnormally 
intensified  sensuality  and  sexual  excitement  that  lead  to  sexual  errors 
that  are  of  etiologic  significance. 


144         GENERAL  PATHOLOGY  AND  THERAPY  OF  IN  CANITY. 


Civil  Condition. 

Insanit}'  is  nuioh  more  frequent^  in  the  single  than  in  the  mar- 
ried, the  explanation  of  which  Hagen  finds  in  the  circumstance  that 
in  the  population  at  large  there  is  an  excess  of  persons  of  unmar- 
riageable  age;  in  the  fact  that  at  this  period  of  life  there  is  greater 
])ossibility  of  becoming  diseased;  that  usually  any  previous  mental  dis- 
turbance renders  marriage  more  difficult;  and,  finally,  that  the  better 
hygienic  conditions  of  married  life  and  regular  sexual  relations  exert 
a  prophylactic  influence. 

On  the  other  hand,  however,  the  married  state  may  create  dangers 
for  the  mental  health,  in  that  the  characters  of  the  husband  and  wife 
may  not  be  congenial :  that  the  need  to  support  a  family  makes  greater 
demands  upon  the  mental  and  physical  activities;  and  that  misfor- 
tunes of  all  kinds  may  change  the  struggle  for  existence  to  despair. 
Faults  of  character,  expensive  habits,  coquetry,  vexations,  and  possible 
uterine  disease  and  hysteria  in  the  wife  may  destroy  the  husband's 
peace  of  mind ;  while  brutal  treatment,  drunkenness,  and  unfaithful- 
ness on  the  part  of  the  husband  may  affect  the  wife. 

A  form  of  insanity  peculiar  to  wives,  not  infrequently  occurring  outside 
of  asylums,  that  is  often  a  source  of  family  misfortune,  is  described  by 
Brosius.  It  is  manifest  in  a  chronic  painful  depression,  with  great  irritability 
toward  the  husband,  even  to  the  extent  of  violent  expressions  of  anger.  This 
depression  of  feeling  is  founded  on  groundless  complaints  of  aversion  and  un- 
faithfulness on  the  part  of  the  husband.  The  husband  and  his  supposed 
favorites  are  exposed  and  scolded.  Jealousy  and  anger  make  these  wives 
spies.  Their  formal  logic  and  the  possibility  of  the  truth  of  their  complaints 
deceive  the  public  as  to  their  abnormal  state  of  mind,  even  when  the  reckless- 
ness of  their  conduct  is  remarkable  enough. 

Age. 

Age,  in  its  relation  to  the  possibility  of  the  occurrence  of  insanity, 
varies  extremely.^ 


^ Hagen,  "Statistische  Untersuchungen": — 
Male:       61.0  per  cent,  single,  35.8  per  cent,  married,    2.5  per  cent,  wido'ivers  or  separated. 
Female  :  54.9  per  cent,  single,  33.6  per  cent,  married,  11.1  per  cent,  widows  or  separated. 

=■  Hagen,.  ihid.  Insanity  under  the  age  of  15  is  very  rare  (1  to  72,752 
inhabitants;  and  35  males  to  7  females).  The  percentage  rises  quite  rapidly 
from  this  age  in  both  sexes  (from  16  to  20  years — 1  to  4010  inhabitants),  and 
continues  about  equal  until  35.  From  36  to  45  it  maintains  about  this  per- 
centage in  men,  but  decreases  almost  one-half  in  women.  After  46  the  per- 
centage falls  about  equally  in  both  sexes. 


THE  CAUSES  OF  INSANITY.  145 

As  Tigges  says,  these  facts  show  insanity  to  ho  an  organic  proc- 
ess, mainly  associated  with  inner  life-conditions  in  the  individual  and 
accompanying  his  development. 

From  this  it  follows  that  the  In'cadtJi  and  nature  of  the  disease- 
pictnre  must  correspond  exactly  with  the  lieight  of  developinont  of  the 
mental  life  of  tlie  individual. 

(a)  Childhood. — J\[cntal  disease  in  childhood — i.e.,  from,  birth 
until  the  time  of  puberty — is  ixn  infrequent  phenomenon.  This  is  to 
be  understood  by  consideration  of  the  incompleteness  of  the  develop- 
ment of  the  mind  of  the  child,  and  the  lack  of  a  great  number  of 
injurious  influences  that  affect  the  brain  of  the  adalt  (struggle  for 
existence,  emotions,  passions,  excesses,  etc.). 

The  etiologic  factors  in  the  mental  diseases  of  childhood  are 
almost  exclusively  organic  and  somatic.  In  tlie  vast  majority  of  ca^es 
we  have  to  deal  with  hereditarily  predisposed  organizations  that  were 
already  defective  in  their  embryonic  stage  of  development.  Insan- 
ity, therefore,  appears  for  the  most  part  in  a  congenital  form;  as 
idiocy  developed  in  the  earlier  years  of  life;  as  moral  insanity;  or  it 
occurs  in  association  with  neuropathic  conditions  like  chorea  and 
epilepsy. 

Along  with  the  original  neuropathic  constitution,  other  important 
etiologic  factors  that  are  frecpient  and  early  are  onanism,  acute,  severe, 
and  especially  infectious  diseases;  external  head  injury;  mental  over- 
exertion; and,  in  a  few  cases,  irritation  by  worms.  Psychic  causes, 
like  passions  and  defective  education,  play  a  very  small  role  in  the 
etiology  of  insanity  in  children.  The  former  do  occur,  and  sometimes 
lead  to  suicide;  but  they  pass  away  more  c|uickly  than  in  the  mature. 
More  important  as  an  exciting  cause  is  fright.  Thus  is  explained  the 
fact  that  the  insanity  of  childhood,  even  when  it  occurs  aside  from  the 
degenerate  forms  of  intellectual  and  moral  imbecility,  or  epileptic 
mental  disease,  usually  takes  the  form  of  an  organic,  idiopathic  dis- 
ease. In  consequence  its  prognosis  is  usually  unfavoralde;  but  it  is 
rendered  even  more  so  by  the  fact  that  insanity  affects  a  mind  that 
is  still  undeveloped,  and  this  endangers  in  a  great  degree  further  ps}'- 
chologic  and  organic  development. 

The  undeveloped  state  of  the  ego  does  not  permit  the  occurrence 
of  the  great  number  of  forms  of  insanity  that  are  observed  in  the 
mature. 

Maudsley  and  Schule  have  shown  Mdiat  forms  are  possible  at  the 
various  stages  of  development  of  the  mind  of  the  child,  and  also  those 
that  actually  occur. 


146         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

During  the  earh'  period  of  life,  just  as  in  animals,^  only  sensorimotor, 
maniacal,  and  impulsive  forms  of  insanity  are  possible  (cases  reported  by 
Maudsley).  With  the  development  of  the  higher  senses,  forms  of  insanity 
^vith  hallucinations  occur  ■which  have  their  origin  in  febrile  conditions,  like 
the  acute  exanthemata,  or  result  from  chorea  or  epilepsy. 

With  the  development  of  the  intellectual  sphere  the  conditions  for  the 
origin  of  delusions  arise.  Still,  in  childhood  systematic  delusions,  like  those 
characteristic  of  paranoia  in  the  adult,  do  not  occur,  even  thougli  the  begin- 
ning of  this  form  of  disease  (fantastic  delusions  as  the  substratum  of  later 
lixed  ideas)  may  sometimes  be  traced  back  to  the  earliest  years  of  childhood. 
Too,  the  insanity  of  imperative  ideas  often  takes  its  urigiu  Ix'fore  the  time  of 
puberty. 

Melancholia  and  mania  are  infrequent  and  are  almost  never  founded  upon 
emotional  states,  but  rather  upon  organic  conditions  (Schule).  The  former 
occurs  as  melancholia  with  stupor,  often  with  impulsive  acts  like  suicide;  the 
latter  occurs  as  a  state  of  excitement  characterized  by  impulsive  movements, 
grave  disturbances  of  consciousness,  great  confusion  of  thought  almost  devoid 
of  associations,  and  is  usually  the  result  of  direct  organic  causes  (fluxionary 
cerebral  hyperemia),  and  sometimes  of  a  defective  (idiotic)  brain. 

(h)  Puberty. — At  the  age  of  sexual  development  the  percentage 
of  insanity  increases  rapidl3^  As  in  all  the  physiologic  phases  of  life, 
the  hereditary  factor  here  constitutes  the  greatest  predisposition.  Ac- 
cording to  Hagen's  investigations,  in  those  that  are  hereditarily  pre- 
disposed the  percentage  is  the  highest  from  the  age  of  16  to  20. 

According  to  my  own  experience,  females  are  more  predisposed 
than  males,  probably  because  the  hereditary  factor  plays  a  more  impor- 
tant role  in  woman,  and  the  period  of  evolution  in  the  female  is  more 
momentous,  and  is  frequently  accompanied  by  grave  disturbances  of 
nutrition  (anemia,  chlorosis). 

Upon  the  basis  of  hereditary  predisposition  the  accessory  factor  of 
development  at  puberty  may  induce  insanity  in  various  ways. 

In  many  cases  onanism  is  a  factor  Avhich,  in  predisposed  indi- 
viduals, arises  very  easily  as  a  result  of  the  abnormally  premature  and 
powerful  sexual  impulse,  and  thus  becomes  an  exciting  cause.  In 
females  at  this  time  abnormal  position  of  the  uterus  or  lack  of  develop- 
ment of  that  organ  from  an  infantile  state,  devoid  of  influence  until 
this  period,  may  act  directly  through  sympathy  and  reflex  influence 
upon  the  cortex;  or  they  may  act  through  the  intermediate  conditions 
they  induce,  such  as  general  disturbance  of  nutrition  (anemia,  chlo- 
rosis). Not  less  important  are  abnormally  rapid  growth  and  arrest  of 
development  of  the  skull. 


^Thus,  maniacal  paroxysms  are  not  infrequent  in  elephants;  and  a  case 
of  a  cow  that  became  maniacal  after  dropping  a  calf  is  reported  in  Henke's 
journal. 


THE  CAUSES  OF  INSAXITY.         ,  147 

In  other  cases  we  are  unable  to  discover  the  manner  in  whicli 
puberty  acts.  ISTot  infre(|uently  the  jisychosis  flisap])ears  with  the 
regular  establishment  of  monstrualioTi. 

The  various  mental  diseases  occurring  at  this  period  of  life,  owing  to  the 
varied  nature  of  the  jjathogenesis,  are  extremely  numerous.  As  mif^ht  be  ex- 
pected from  the  dominating  influence  of  hereditary  predisposition,  the  degen- 
erate forms  of  insanity  play  the  most  important  role.  Paranoia,  insanity  of 
imperative  ideas,  periodic  and  circular  insanity,  and  constitutional  melancholia 
not  infrequently  begin  at  this  time,  and  moral  insanity  is  also  notable  as  fre- 
quently beginning  at  this  period. 

Melancholia  and  maniacal  cases  also  occur,  but  less  frequently  in  the 
benign  form  of  a  psychoneurosis  with  an  emotional  manner  of  origin  (usually 
as  a  result  of  fright)  ;  rather  as  primary  and  direct  organic  conditions  similar 
to  those  that  occur  in  children. 

Melancholia  occurs  in  the  grave  stuporous  form,  or  with  impulsive  acts, 
imperative  ideas,  and  hallucinations  that  are  directed  toward  the  person's  own 
life;  still  more  frequently  toward  incendiarism.  This  latter  tendency  has 
given  rise  to  the  erroneous  distinction  of  so-called  pyromania  at  the  age  of 
puberty.  The  maniacal  forms,  for  the  most  part,  take  on  moria-like  features, 
and  are  likewise  very  impulsive. 

At  the  same  time,  not  infrequently,  especially  in  cases  where  the  groAvth 
of  the  skull  and  brain  has  been  interfered  with,  we  observe  grave  states  of 
fluctionary  mania,  or  states  of  delirium  and  hallucinatory  excitement  with  all 
the  symptoms  of  brain  hyperemia,  with  rapid  course,  and  ending,  for  the  most 
part,  in  lasting  states  of  mental  weakness.  For  at  this  age,  all  idiopathic 
forms  of  mental  disease  are  exceedingly  dangerous  in  that  they  interfere  with 
the  further  development  of  the  brain. 

Too,  epileptic  and  hysteric  insanity  develop  with  especial  frequency  at 
the  age  of  puberty.  Upon  an  hysteric  basis  are  observed  the  mild  chronic 
manias,  tisuallj^  with  an  erotic  nucleus  (desire  to  enter  a  cloister,  etc.) ;  also 
episodic — partly  hallucinatory,  partly  cataleptic — states  of  insanity;  and 
finally  cases  of  religious  paranoia. 

Kahlbaum  and  Hecker  describe  a  juvenile  form  of  disease  imder 
the  term  hebephrenia  that  occurs  especially  during  the  years  of 
pubert}'^  from  18  to  22,  and  passes  frequently  into  dementia. 

This  form  of  insanity,  besides  the  special  period  of  its  occurrence,  is  said 
to  be  characterized  by  the  protean  variations  of  its  symptoms  (melancholia, 
mania,  confusion)  ;  by  the  great  rapidity  with  which  it  passes  on  to  a  state  of 
mental  weakness;  and  by  the  peculiar  form  of  the  resulting  dementia,  the 
signs  of  Avhich  may  be  recognized  in  the  first  stages  of  the  disease  (silly, 
important  manner).  At  the  same  time,  the  superficiality  of  the  changing  emo- 
tions is  remarkable  (laiighing  and  joking  at  the  height  of  melancholic  depres- 
sion) ;  so  that  it  would  seem  that  the  patient  was  playing  Avith  his  anomalies 
of  feeling. 

During  the  phases  of  excitement  there  is  foolish,  purposeless  activity  and 
impulse  to  Avander  about,  Avith  the  appearance  of  being  conscious  of  the  silly 
speech  and  action.  Too,  the  form  of  speech  of  these  patients  is  silly,  consist- 
ing   usually    of    high-sounding,    but    senseless,    phrases.       At    the    same    time 


]^S       ^;^^^•l^R.\L  tatiiology  and  tiikkai'Y  of  jx^amiy. 

llicre  is  preference  for  foreign  words  and  strong  expressions,  incapability  of 
expressing  a  thoiiglit  in  a  coneise  form,  and  illogical  formation  of  sentences 
and  pecnliar  forms  of  construction. 

Delusions  are  said  to  be  inficqucnt,  and  when  they  do  occiu'  they  are 
but  rudimentary, elements  of  ideas  of  persecution;  but,  as  a  rule,  there  are 
merely  strange,  silly  thoughts.  Occasionally  states  of  excitement  going  to 
the  degree  of  mania  are  induced  by  onaiiiMii.  menstrual  ili>lui-l)anccs,  and 
hallucinations. 

'J'iie  justilication  of  regaiiling  hcl)c|>ln('nia  as  a  peculiar  t'unu  of  disease 
seems  to  me  to  be  still  (lucstionabic. 

At  any  rate,  it  is  a  degenerate  psychosis  (puberty,  protean  form,  im- 
pulsive acts,  prechmiinating  formal  and  ail'ective  ilisturbances,  i)rinu)rdial  cimr- 
acter  of  any  delusions  with  tnipleasant  content,  with  or  without  very  silly 
motives).  The  weak-minded  silliness  of  the  disease-picture  is  partly  to  be  ex- 
plained by  the  original  weak-mindedness  of  the  patient,  which  Hcckcr  empha- 
sizes in  the  etiology  of  his  cases;  and  partly,  as  the  aiilliDv  mentioned  shows 
in  his  psychologic  description  of  them,  by  tlie  al)uonnal  process  itself,  which 
begins,  as  it  were,  in  the  very  earliest  period  of  mental  life,  and  tlius  sets  a 
limit  to  further  development  of  the  mind. 

In  harmony  with  Schule,  who  in  GOO  cases  met  but  2  cases  of  ])ure  hebe- 
phrenia, I  have  found  the  psycljosis  in  question  to  be  very  infrequent  (8  cases 
in  3000).  In  all  my  cases  there  were  decided  hereditary  predisjiosition,  original 
mental  weakness,  and  signs  of  degeneration.  In  2  cases  in  females  there  was 
microcephaly.  The  prognosis  is  not  absolutely  bad.  In  1  case  recovery 
occurred,  and  in  another  lasting  improvement  was  obtained. 

Featiu-es  of  hebephrenic  insanity  are  also  noticeable  in  the  mania  that 
occurs  at  the  time  of  puberty,  along  Avith  the  other  characteristics  of  the 
psychoneuroses,  and  which  runs  a  favorable  course.  Probably  hebephrenia  is 
only  a  form  of  pubescent  insanity  in  general;  ä  phenomenon  dependent  upon 
serious  predisposition  and  the  sillj'  character  of  speech,  writing,  and  conduct 
that  belongs  to  the  peculiar  biologic  phase  during  which  pubescent  insanity 
develops.  That  the  same  psychosis  may  take  on  peculiar  features  in  accord- 
ance Avith  the  age  at  which  it  develops  is  sliown  by  cases  of  melancholia  an<l 
mania  occurring  in  old  age,  whicli  difler  from  similar  cases  occui  ring  in  youth 
or  at  maturity. 

r'.vsf':  1. — ]\Iaii]'aeal  iiiSfiniiy  at  pul)eriy  with  liclicplireiiic  synip- 
loms.     Ecc'overy. 

Miss  Z.,  aged  19,  comes  of  tainted  family;  maternal  grandmother  was 
weak-minded;  two  maternal  vmcles  died  insane,  one  by  suicide.  Her  mother's 
character  Avas  abnormal:  one  brother  is  an  idiot.  The  patient  Avas  not  so 
well  endowed  mentally  as  her  elder  sister;  she  developed  slowly,  both  men- 
tally and  physically,  and  manifested  from  the  beginning  a  retiring  character, 
and  was  depressed  by  realizing  that  she  was  not  equal  to  her  sister  in  mind 
and  appearance.  The  patient  has  never  had  any  severe  illness;  menses  began 
at  the  age  of  17  without  disturbance,  and  I'ecurred  thereafter  regularly;  since 
the  beginning  of  puberty  the  patient  has  at  times  seemed  somewhat  elated, 
excited,  and  passionate.  An  old  strict  goA-erness  conducted  her  education,  and 
sought  to  keep  the  girl  in  the  nursery  as  long  as  possible,  and  childlike  iu 
mind.  , 


TTIK  CIAIISKS  OF   INSAXI'I'V.  ]  \<j 

In  Doopmlier,  1870,  it  was  doienniiuid  to  iiilrodiicf!  thr;  young  lady  to 
society.  She  began  witli  a  journey  to  Italy.  In  January,  at  Naples,  it  was 
noticed  that  she  became  inconstant,  excited,  and  elated;  she  began  to  take 
an  enthusiastic  interest  in  all  that  was  noble  and  beautiful;  she  found  the 
beauties  of  Naples  charming,  and  began  to  busy  herself  with  thoughts  of 
marriage,  lor  she  niTist  ncnv  become  independent,  since  she  was  no  longer  a 
child,  and  up  to  this  time  liad  allowed  herself  to  be  led  too  much  by  others. 
She  played  the  mother  to  her  aunt  and  elder  sister,  and  gave  them  good 
advice;  but  at  the  same  time  she  was  still  child  enough  to  play  with  other 
young  girls  occasionally,  and  to  forget  her  project  of  acting  and  being  a  great 
lady.  Her  state  of  feeling  alternated  between  supremely  happy  moods  and 
depression  and  tearful  anxiety  about  her  health.  The  patient  was  very  emo- 
tional, and  the  refusal  of  a  wish  was  capable  of  throwing  her  into  violent 
excitement.  Though  she  was  childlike  in  her  thoughts  and  wishes,  she  still 
liked  to  attract  attention  by  efforts  to  play  the  lady,  and  often  with  ludicrous 
pathos  said  that  she  would  no  longer  allow  herself  to  be  treated  as  a  child. 

In  Jime,  1880,  before  the  period  of  menstruation,  the  disease  which  here- 
tofore had  been  but  slightly  indicated  increased  to  well-marked  maniacal  ex- 
altation. She  slept  badly,  became  restless  and  talkative,  showed  constant 
activity  of  thought,  and  became  amenomaniaeal.  She  said  that  she  was 
supremely  happy,  and  found  everything  to  be  wonderfully  beautiful;  she  sang, 
jumped,  and  danced,  and  at  times  was  also  religiously  excited. 

With  the  occurrence  of  the  menses  there  was  a  return  to  the  previous 
state.  In  the  middle  of  July  there  was  another  premenstrual  exacerbation, 
this  time  with  erotic  features.  She  thought  that  a  young  man  whom  the 
family  had  intended  for  her  husband,  but  whom  she  had  not  seen  since  her 
sickness,  was  concealed  in  the  house,  and  she  was  not  allowed  to  see  him.  On 
account  of  this  she  scolded  her  relatives,  became  very  much  irritated,  and 
sought  her  intended  in  every  corner  of  the  great  castle.  After  a  remission 
following  the  menses,  with  the  return  of  them  in  August  a  marked  recurrence 
of  the  disease  occurred.  She  became  very  restless,  exalted,  and  was  in  a  state 
of  constant  emotional  excitement.  She  would  go  into  ecstasies  over  a  dry 
twig  in  the  park  or  a  wild  flower;  she  exhibited  great  variation  of  feeling, 
and  expressed  a  multitude  of  rapidly  changed  Avishes  and  desires;  she  became 
very  talkative,  with  disconnected  thoughts.  From  the  beginning  of  August 
the  patient  took  daily  4  grams  of  sodium  bromide. 

Her  condition  at  the  beginning  of  September,  1880,  on  the  occasion  of  a 
consultation,  showed  nothing  physically  wrong,  with  the  exception  of  con- 
tinued, but  slight,  fluxion  to  the  head,  retarded  menses,  disturbed  sleep,  and 
complaints  of  occasional  headache.  Psychically  there  were  symptoms  of  slight 
maniacal  exaltation,  which  she  was  able  to  restrain  under  examination,  with 
hebephrenic  features.  The  patient  talks  without  end,  loses  herself  in  tiresome 
details,  and  is  hasty  in  her  movements.  Her  state  of  feeling  constantly 
changes  from  cloud  to  sunshine:  now  laughing,  now  weeping.  She  is  able  to 
control  herself  before  strangers  and  in  the  drawing-room,  but  while  walking 
in  the  forest  she  rolls  in  the  grass  sometimes  for  very  pleasure.  For  hours 
at  a  time  she  walks  very  rapidly,  so  that  one  can  scarcely  keep  up  with  her 
without  fatigue. 

The  patient  is  a  peculiar  mixture  of  child  and  lady.  It  is  noticeable  that 
she  is  half-child,  that  she  has  been  out  of  the  nursery  but  a  short  time  while 


150  GENERAL  PATHOLOGY  AND  TIIEnAPY  OF  INSAM  TY. 

at  the  snnio  time,  she  seeks  to  phiy  the  j,n;in(l  lady,  and  is  not  yet  grown  np 
to  this  role.  81ie  seeks  to  eopy  and  pose.  l>iit  is  coiislnntly  sliowinji'  her  lack 
of  abilit}";  she  seeks  to  cover  up  her  failure  by  certain  nonchalance  and 
aplomb,  but  in  this  she  becomes  irresistibly  funny  and  grotesque.  Her  manner 
of  conversation  also  reveals  the  biologioo-psyohic  state  of  transition  in  which 
she  is.  Her  talk  is  inexhaustible  and  changeable,  as  is  usual  in  one  maniacal; 
and,  owing  to  errors  in  expression  and  overfineness  of  sjieech,  along  with 
coarse  and  even  slang  phrases  and  strong  language,  her  conversation  acquires 
]it'culiar  featiu'cs;  and  this  is  also  true  by  reason  of  curious  trains  of  thougiit, 
wherein  there  is  an  a.ssociation  of  childish  and  more  mature  remarks. 

The  jKitient  is  also  in  a  peculiar  transitory  phase  sexually  from  a  child 
to  a  maid.  She  has  notions  of  sexual  relations,  but  seems  still  to  be  quite 
childlike.  Her  romantic  love  for  her  'Movit."  to  wliom  she  is  engaged,  is  tlie 
result  of  sympathy  of  feelings,  a  cliildisii.  ideal  passion,  and  notliing  less  tlian 
a  conscious,  passionate,  earnest  inclination. 

In  this  it  is  evident  that  the  childlike  form  is  not  yet  completely  de- 
stroyed, and  the  new  not  yet  completely  developed.  Still  more  clearly  is  tlie 
hebephrenic  coloring  of  the  disease-picture  expressed  in  the  intimacy  of  the 
family  and  the  letters  of  the  patient.  The  patient  gives  her  elder  sister  a 
superfluity  of  good  advice,  and.  comforts  her  by  saying  there  will  also  be  found 
a  good  husband  for  her;  she  plays  mother  to  her  aunt,  and  cautions  her  to 
take  good  care  of  her  elder  sister,  that  she  may  not  lose  her' heart  too  easily; 
she  writes  long  letters  to  her  brother,  telling  him  to  be  virtiious,  as  if  she 
were  his  grandmother;  and  she  writes  in  a  silly  strain  to  a  friend  and  recom- 
mends a  course  of  reading  for  her  during  the  long  winter  evenings,  telling  her 
she  must  take  the  place  of  a  mother  to  her  sister;  she  takes  pleasure  in  order- 
ing about  the  governess  and  other  servants,  and  grows  angry  when  she  dis- 
covers that  she  is  not  minded,  or  is  called  "dear  child."  "i  have  been  too 
good ;  I  must  become  more  strict,  else  everything  will  go  wrong  in  the  house ; 
I  must  be  a  man."  At  the  same  time  she  writes  silly  verses  about  the  gov- 
erness and  laughs  immoderately. 

In  September  and.  October  the  patient  becomes  maniacally  exalted,  will) 
some  exacerbation  at  the  time  of  the  menses;  she  runs  about  in  the  house; 
seeks  to  place  herself  above  everybody;  is  for  the  most  part  pleasant,  but 
irritable  and  easily  excited  to  anger  at  the  slightest  cause;  at  the  same  time 
she  is  disobedient  and  hard  to  manage;  now  seeming  like  one  Avho  has  been 
devoid  of  all  training,  and  at  another  time  like  a  silly  child.  She  runs  about 
in  the  park,  drums  pieces  on  the  piano,  sticks  to  nothing,  and  does  everything 
in  great  haste.  She  takes  to  Avriting  many  letters  full  of  euphemious  phrases 
and  silly  sentences.  Her  peculiar  manner  of  speech  and  writing  is  noticed  by 
those  around  her.  She  maltreats  the  governess,  whose  advice  is  refused, 
since  she  has  ended  her  education.  The  patient  takes  pleasure  in  striking 
manners,  and  her  poses  become  grotesque.  Now  and  then  there  are  hours  of 
jjainful.  morose  depression  and  irritability  (with  expressions  to  the  effect  that 
she  feels  as  if  she  had  some  one's  head)  in  the  amenomaniacal  picture.  Sleep 
is  much  distiu'bed;    congestion  of  the  brain  is  at  times  very  clearly  marked. 

By  the  end  of  October  the  patient  became  quieter,  and  more  orderly;  the 
childlike  features  disappeared  entirely;  the  patient  acted  more  like  a  lady, 
but  frequently  enough  complained  of  the  nursery  and  of  successful  efforts  to 
express  herself  elegantly;    and  coarse  phrases  and  childish  manner  were  still 


THE  CAUSES  OF  INSANITY.  151 

observed.  In  November  maniacal  exaltation  becomes  less  and  the  patient 
gains  an  idea  of  her  condition.  She  is  ashamed  and  tries  to  control  herself ; 
she  becomes  natural  in  feeling  and  thought,  and  gives  up  thoughts  of  love  en- 
tirely. By  the  end  of  December  her  relatives  consider  the  patient  entirely 
well;  but  she  has  reached  only  the  stage  of  development  of  a  girl  of  15  of 
good  education.  The  congestive  disturbances  have  entirely  disappeared,  and 
the  menses  are  regular. 

Later  reports  show  that  the  mental  development  progressed  to  tliat  of  an 
adult  Avithout  any  anomalies  whatever. 

(c)  Age  op  Physical  and  Mental  Maturity. — The  most  favor- 
able time  for  the  origin  of  insanity  is  the  age  of  complete  physical  and 
mental  development — the  period  of  life's  storms,  of  the  greatest  phys- 
ical and  mental  strain.  In  woman  this  is  during  the  period  from  25 
to  35  years  of  age,  for  the  reason  that  at  this  time,  in  single  women, 
hope  of  love  and  life  excite  the  emotions,  so  often  deceived  with  the 
infliction  of  serious  mental  wounds,  while,  in  married  women,  the 
weakening  influences  of  childbirth  and  lactation  make  themselves  felt. 

In  man  the  corresponding  period  is  from  the  age  of  35  to  50, 
because  at  this  time  the  cares  of  occupation  and  family,  and  physical 
and  mental  effort  in  the  struggle  for  existence,  are  most  intense,  and 
these,  with  excesses  in  drink  and  venery,  exercise  their .  exhausting 
influence  on  the  brain.  All  forms  of  insanity  occur  during  this  period 
of  "physiologic  turgescence'^  of  the  brain,  and  of  greatest  intensity 
and  variety  of  stimuli,  but  general  paralysis  is  especially  frequent. 

Climacteric. — The  period  of  involution  in  woman  also  constitutes 
a  predisposing  and  exciting  cause  of  mental  disease. 

Of  878  female  patients  of  my  observation,  there  were  60,  or  6.1 
per  cent.,  in  whom  the  climacteric  was  the  cause  of  the  disease.  Influ- 
ence exerted  to  cause  disease  may  be  psychic  (painful  consciousness 
of  loss  of  social  and  ethic  feeling  based  upon  sexual  feelings,  especially 
in  wives  that  are  childless ;  painful  recognition  of  the  loss  of  physical 
charms) ;  or  it  may  be  mixed,  in  so  far  as  the  abnormal  general  feelings 
accompanying  the  process  of  involution,  and  the  traditional  and  not 
entirely  unfoimded  fear  commonly  entertained  of  this  dangerous  phase 
of  life,  may  shake  the  mental  equilibrium.  The  climacteric  may 
finally  be  the  cause  of  disease  in  a  somatic  way,  in  that  there  is  not 
simply  a  loss  of  function  and  final  atrophy  of  the  sexual  organs,  but  a 
process  of  involution  affecting  the  organism  at  large,  in  which  there 
may  be  decided  disturbance  of  functions  until  the  normal  equilibrium 
is  re-established. 

.The  special  influences  that  are  of  importance  in  causing  insanity 
at  this  period  are  profuse  secretions  (menorrhagia,  leucorrhea)  and 
resultant  disturbance  of  nutrition  of  the  psychic  organ    (anemia)  ; 


153  GEXKRAL  I'A'IIIOLOCV  AM)  TllKltAPV  OF  INSANITV. 

sudden  suppression  of  the  menses  {comp.  "Suppressed  Menses")  ; 
neuralgia,  and  especially  states  of  irritation  in  the  genital  nerves,  with 
the  consequent  irritation  of  the  central  nervous  system  (irradiation, 
reflex). 

The  significance  of  those  factors  is  intonsiticd  by  orgmiic  and 
especially  by  hereditary  predisposition,  by  wcakeiring  iniluoiices  Avliich 
precede  or  occur  simultaneously  with  the  climacteric  (frequent  child- 
birth, exhausting  diseases;  typlioid  and  other  severe  general  diseases; 
local  diseases  of  the  uterus,  especially  chronic  metritis  and  anomalies 
of  position).  Unless  such  accessory  causes  act  simultaneously  with  the 
climacteric,  it  does  not  seem  possible  that  they  could  cause  mental 
disease. 

Insanity  at  the  climacteric  docs  not  present  a  specific  form  of  disease ; 
still  it  cannot  be  denied  that  the  psychoses  arising  at  this  time  may  have 
somatic  features  in  their  beginning  and  course  that  clearly  point  to  the  cli- 
macteric as  their  basis ;  that  sexual  irritation  indiiced  by  the  climacteric 
process — partly  consciously  by  way  of  allegory,  and  partly  unconsciously 
by  direct  excitation  of  the  cerebral  cortex — may  lend  the  disease-picture 
certain  featvu'es  that  may  indicate  quite  definitely  the  sexual  basis  of  the 
malady. 

Moreover,  the  frequently  sexual  content  of  the  delusions  points  to  the 
same  thing  (20  times  in  my  statistics),  as  do  hallucinations  of  smell  (6  times), 
and  states  of  reflex  excitement  of  the  sensory  paths  of  the  spinal  cord  -which 
induce  related  delusions  of  physical  persecution  (10  times).  The  forms  of  dis- 
ease observed  in  these  GO  cases  mentioned  were  acute  delirium  (1),  circular 
insanity  (1),  paranoia  with  primordial  delusions  of  persecution  (3G),  paralytic 
dementia  (12),  and  melancholia  (4). 

Climacteric  melancholia  presents  features  of  senile  melancholia;  at  least 
the  nihilistic  delusions  dependent  upon  an  invalid  brain  condition  (poverty, 
general  annihilation— often  also  with  hypochondriac  coloring)  are  ordinarily 
observed  here.  Too,  states  of  terrible  fear  with  danger  of  suicide  are  very 
frequent. 

The  establishment  of  a  climacteric  for  the  male  sex,  with  the  dis- 
tinction of  the  psychoses  that  occur  at  this  period  (50  to  60  years), 
does  not  seem  justified  either  biologically  or  clinically. 

The  reported  cases  of  psychoses  of  the  male  climacteric  clearly 
belong  to  the  senile  psychoses,  and  are  explained  by  precocious  senility. 

(d)  Senility. — Beyond  the  age  of  50  the  percentage  of  insanity 
falls  rapidly  in  both  sexes.  On  the  other  hand,  in  old  age  the  senile 
involution  of  the  brain  arises  as  a  new  causal  influence.  In  many 
cases  this  appears  even  before  the  age  of  50  (senium  praecox),  when, 
in  the  struggle  for  existence,  the  powers  have  been  used  up,  and 
excesses  and  severe  constitutional  diseases  have  made  the  individual 
decrepit  abnormally  early. 


TIIK  CAIISI'IS  OF   IXSAXri'V.  l^O 

If  this  change  occur  with  intensity  and  rapidity,  he  accompanied 
by  fatty  degeneration  of  the  heart,  arteriosclerosis,  or  atheromatous 
encephalitic  focal  disease  of  the  brain,  then  a  state  of  mental  weak- 
ness is  developed  which,  if  life  last  long  enough,  progresses  to  complete 
dementia  (de^nentia  senilis;  vido  "Special  Pathology").  The  disturb- 
ances of  nutrition  and  circulation  tliat  occur  in  association  with  senile! 
involution  predispose  in  a  high  degree  to  attacks  of  mental  disease. 

The  forins  of  insanity  that  occur  on  the  basis  of  an  invalid  and 
aging  brain  are  melancholia,  mania,  and  forms  of  delusional  insanity. 
The  organic,  degenerative  foundation  gives  these  psychoses  of  the 
invalid  brain  peculiar  features  which  distinguish  them  from  the 
psychoneuroses  of  the  same  name  affecting  the  yonthful,  unburdened 
brain. 

They  are  distinguished  by  their  severe  organic,  idiopathic  charac- 
ter; by  the  accompanying  sensor}^,  vasomotor,  trophic,  and  motor 
disturbances,  reaching  even  the  degree  of  apoplectiform  and  epilepti- 
form attacks;  by  symptoms  of  mental  weakness  manifest  in  all 
directions.  This  weakness  is  manifest  in  the  emotioiial  sphere  by 
superficiality  of  the  emotions,  in  which,  however,  those  that  are 
organically  induced,  like  precordial  distress,  may  find  powerful  ex- 
pression; in  the  intellect,  by  weakness  of  memory,  incoherence,  and 
loss  of  judgment.  Any  delusions  that  occur  are  only  exceptionally 
due  to  reflection;  as  a  rule,  they  are  primordial.  Ko  less  loose  and 
weak  are  the  expressions  of  will  in  these  patients. 

Melancholia  on  a  senile  foundation  is  agitated  and  errabund.  The  impel- 
ling factor  is  the  affect  of  fear.  This  is  only  exceptionally  reactive,  associated 
with  and  induced  by  delusions  and  phantasms  of  the  senses,  but  rather  a 
primary  and  organically  conditioned  symptom.  The  motor  reactions  are  im- 
pulsive unrest,  destructive  acts,  especially  biting  the  fingernails  and  scratch- 
ing the  skin.  At  any  moment  the  affect  of  fear  may  increase  to  the  extent  of 
furor,  and  then  such  patients  become  very  dangerous  to  themselves  and  others. 

Effort  on  the  part  of  the  patients  to  explain  the  abnormal  feelings  are 
but  infrequent,  and  when  they  do  occur  are  silly. 

Self-accusation  is  infrequent.  In  its  place  mieromaniacal  and  nihilistic 
delusions  occur,  which,  when  completely  developed,  consist  of  negation  of  ex- 
istence of  self  and  others;    indeed,  of  the  world  at  large. 

It  is  quite  usual  to  meet  with  the  delusion  that  everything  has  been  de- 
stroyed, or  that  the  patient  is  no  longer  able  to  pay  his  way,  which  gives  rise 
to  refusal  of  food;  but,  owing  to  the  superficial  character  of  the  emotions, 
this  is  easily  overcome,  and  a  temporarily  inordinate  appetite  takes  its  place. 

Hypochondriac  nihilistic  delusions  also  occur  (false  body,  false  organs, 
false  head,  etc.).  Disturbances  of  sensibility  and  general  feeling  and  illusions 
are  sometimes  the  foundation  of  these  impossible  delusions;  as  a  rule,  how- 
ever, they  are  primordial  creations  of  the  brain  that  is  suffering  in  its 
nutrition. 


l."l  genet; AT.  PATTTOLOnV  .\\1^  'nnCKAPY  OF  INSANITY. 

The  manias  which  develop  upon  the  basis  of  senile  degeneration  have 
grave  idiopathic  features.  They  resemble  the  picture  of  paralytic  mania,  in 
that  they  are  characterized  by  purposeless  plans,  silly  and  busy  occupation, 
senseless  delusions  of  grandeur,  and  erotic  excitement  with  loss  of  all  moral 
ideas:  by  intolhH'tunl  weakness  and  ethic  defect  in  all  directions;  and  at  times 
the  mania  may  increase  to  brutal,  usually  angry,  furor,  with  symptoms  of  con- 
gestive cerebral  hyperemia. 

The  pictures  of  delusional  insanity  as  states  of  episodic  or  linal  inanition 
of  the  degenerating  brain  are  pecidiar  in  the  predominance  of  nihilistic  and 
lai-gely  hypochondriac  primordial  dcliria,  and  their  foolish  content  and  hopeless 
incoherence.  The  reactive  ciiKdioiis  are  weak  and  foolish,  if  precordial  anxiety 
does  not  intensify  the  situation  to  a  draniatiL'  lieight.  In  the  latter  case  sui- 
cide and  homicide  are  to  be  expected. 

Otherwise  childish  fear  of  a  terrible  death,  with  a  silly  motive  and  re- 
active weak-minded  monotonous  screaming  and  crying,  dominates  the  scene. 

There  may  be  hostile  apperception  and  great  mistrust  of  others;  episodic 
frightful  lialhicinations  of  blood,  general  slaughter,  colTms,  corpses,  gallows; 
abrupt  deliria  of  poisoning,  of  the  end  of  the  world,  etc. 

These  psychoses  of  the  invalid  brain  have,  of  course,  an  unfavor- 
able prognosis.  As  a  rule,  they  are  forerunners  or  episodes  of  senile 
dementia ;  only  in  a  few  cases  does  recovery  take  place  without  mental 
weakness. 

Besides  these  senile  psychoses  in  the  narrower  sense,  in  indi- 
viduals whose  brains  have  remained  free  from  senile  degeneration  at 
an  advanced  age,  benign  psychonenroses  occur  which  do  not  differ 
from  those  that  develop  at  an  early  period  of  life. 

Occupation  and  Circumstances  of  Life. 

These  form  a  factor  which,  in  spite  of  all  efforts  of  statistics,  is 
too  complicated  to  afford  satisfactory  etiologic  results. 

Sailors,  coopers,  and  teamsters  frequently  become  insane,  but  the 
cause  of  this  lies  not  so  much  in  the  calling,  as  in  the  alcoholic  excesses 
usually  associated  with  it. 

In  those  working  with  fire  caloric  influences  not  infrequently 
induce  insanity. 

Governesses  become  insane  quite  frequently.  Homesickness; 
impleasant  family  and  social  relations  that  often  drive  these  poor 
creatures  away  from  home;  insulting,  harsh  treatment;  in  gen- 
eral, depressing  social  position;  disappointed  love;  over-exertion  in 
work,  appear  usually  as  causes. 

Prostitutes  become  insane  not  infrequently,  probably  as  a  result 
of  over-irritation  of  the  nerves  by  sexual  excesses,  drink,  misery,  and 
syphilis. 


TTTFv  CATISI':R  OF  INSANITY.  ^r>r, 

The  lower  classes  are  afllicied  witli  the  ciirso  of  povei'ty,  social 
misery,  insufficient  food,  bad  homes,  and  the  resulting  scrofula,  rickets, 
and  tuberculosis;  besides,  often  by  excesses  in  alcohol,  and  that  of  the 
^Aforst  and  most  deleterious  kind,  and  thus  they  easily  succumb  in  the 
struggle  for  existence.  In  the  higher  classes,  hereditary  influences, 
nervousness,  misdirected  education,  excesses  of  all  kinds,  passions, 
pride,  etc.,  are  equivalents. 

Persons  working  with  the  head  are  more  predisposed  than  those 
that  labor  with  the  hands;  still,  mental  over-exertion  is  hardly  capable 
of  causing  insanity  in  a  mature  person.  In  such  cases  there  is  always 
at  the  same  time  a  neuropathic  constitution,  or  trouble,  care,  and 
reverses  at  home,.or  trouble  with  superiors;  or  it  may  be  the  case  of  an 
individual,  apparently  the  child  of  fortune,  who  by  accident  or  favor 
has  obtained  a  situation  for  which  he  is  incompetent,  and  which,  with 
mental  overwork,  loss  of  sleep,  and  the  help  of  stimulants,  he  seeks 
to  retain.  The  foundation  for  the  psychoses  that  arise  out  of  such 
excessive  demands  upon  the  brain  are  states  of  cerebrasthenia.  If  the 
vessels  are  abnormally  pervious,  acute  delirium  or  paralytic  dementia 
easily  occurs.  In  the  youthful  individual  they  result  in  melancholia, 
acute  dementia,  and  acute  hallucinatory  insanity. 

The  injurious  influence  of  mental  over-exertion  upon  the  youthful  brain 
still  in  a  stage  of  development  cannot  be  denied.  It  is  only  too  evident  that 
in  our  neuropathic  age  too  much  and  too  great  a  variety  of  work  are  demand  el 
of  the  brain  of  the  pupil,  and  the  body  is  too  little  considered  in  schools.  The 
schools  are  essentially  nothing  but  preparatory  schools  for  future  philologists, 
and  it  is  high  time  for  reform  in  the  method  of  education.  Hasse  has  pointed 
tliis  out;  but  he  has  actually  over-estimated  the  injurious  influence  of  this 
overburdening,  in  such  cases  there  are  always  other  predisposing  and  assist- 
ing causes  (hereditary  taint,  neuropathic  constitution,  mental  limitation, 
onanism,  too  strict  discipline  in  school  and  at  home,  injured  pride,  lack  of 
progress.,  etc.).  Hasse's  cases  were  essentially  instances  of  mental  exhaustion 
with  symptoms  of  irritation. 

The  frequent  occurrence  of  insanity  in  artists,  poets,  and  noted 
actors  has  been  observed. 

The  fine  organization  which  renders  such  individuals,  who  are 
for  the  most  part  neuropathic,  capable  of  extraordinary  activities, 
seems  to  be  accompanied  by  a  lessened  power  of  resistance  of  the  brain 
to  irritants.  Perhaps,  too,  the  constant  nervous  excitement  of  such 
persons,  and  irregularity  in  their  manner  of  life,  should  be  taken 
into  consideration. 

In  soldiers  homesickness,  bad  food,  onanism,  physical  exertion, 
and  brutal  treatment  by  superiors  are  effective.  The  greater  mor- 
bidity of  officers  is  to  be  explained  by  excesses  of  all  kinds,  with  ina- 


l,-,(;       (;k.\i;i!.\i.  i'a  ^ll()l.()(;^■  and  riii:i;Ai'\  oj'  ixsani'in'. 

bility,  owing  to  strictness  of  discipline,  to  rest  after  debauches;  the 
single  state;  degradation  in  rank;  insults  that  must  be  endured, 
owing  to  discipline. 

Still  more  considerable  is  the  number  of  cases  of  insanity  during:  actual 
war,  due  to  consequent  increase  of  Avoiinds,  liardsliips,  etc. 

The  great  wars  of  later  decades  have  ollered  abundant  upportunit}'  of 
observation  of  such  war-psychoses.  Along  with  the  ordmary  psychoses, 
severe  idiopathic  forms  of  insanity,  especially  jjaralj'sis,  with  bad  prognosis, 
predominate.  The  reason  for  this  lies  apparently  in  the  fatiguing  and  ex- 
hausting influences  of  life  during  the  time  of  war.  Of  the  first  importance  is 
physical  over-oxortion  due  to  lack  of  sloe]),  exposure  to  licat  and  cold,  forced 
marches,  bad  liousing.  and  often  insunicicnt  food,  for  which  a  substitute  is 
sought  in  alcoholic  excesses.  Of  next  importance  are  the  increased  demands 
on  the  mental  activities  resulting  from  strict  discipline  in  the  face  of  tlic 
enemy,  and  the  exciting  impressions  of  battle.  Besides  there  is  anxiety  about 
relatives,  their  support,  homesickness,  loss  of  relatives  and  comrades — all 
these  mental  factors  intensified  in  a  defeated  army  by  the  panic  of  pursuit, 
the  patriotic  despair  at  defeat  and  imprisonment;  and  finally  the  injurious 
influence  of  exhausting  diseases,  like  typhoid,  dysentery,  etc. 

The  exhausting  influence  of  war  is  clearly  shown  by  Arndt's  observation, 
according  to  which,  during  a  war,  in  the  majority  of  combatants,  there  is  de- 
veloped a  certain  nervous  and  mental  irritability  that  leads  to  numerous 
excesses  and  insubordination,  and  that  disappears  only  after  months  or  years 
of  rest.  As  phenomena  of  exliaustion,  Arntlt  mentions  great  tendency  to 
fatigue,  inability  to  think,  listlessness,  inability  to  work  in  the  usual  Avay, 
with  consequent  dissatisfaction  with  self  and  the  world,  sleepiness  and  sleep- 
lessness, great  irritability,  apprehension,  tendency  to  fear,  and  indelinite  liypo- 
ehondriac  thoughts  even  to  the  degree  of  tcedium  fitw. 

From  these  neurasthenic  conditions  it  is  but  a  step  to  actual  mental  dis- 
ease.    A  slight  accessory  injurious  influence  may  cause  its  development. 

Imprisonment. 

The  great  frequency  of  insanity  among  prisoners  is  a  statistic  fact. 
The  causes  of  this  lie  not  exclnsively  in  the  imprisonment,  but  essen- 
tially in  the  former  manner  of  life  and  certain  predispositions  that 
affect  criminals.  Many  criminals  have  suffered  with  unrecognized 
mental  disease  before  the  beginning  of  imprisonment.  Many  are 
organically  burdened,  or  they  are  men  predisposed  by  having  lived  a 
life  of  misery,  degradation,  filth,  and  sensuality,  and  in  whom  impris- 
onment becomes  only  an  accessory  cause  of  disease. 

Other  not  unimportant  factors  that  e.xert  an  influence  before  im- 
prisonment are  poverty,  misery,  c|ualms  of  conscience  as  a  result  of  the 
criminal  act,  anxiety  about  success,  fear  of  discovery  and  arrest,  and 
the  torture  and  misery  of  trial  and  sentence.  To  these  are  added  the 
unhygienic  conditions  of  prisons — lack  of  fresh  air  and  exercise,  lack 
of  food,  onanism — with  the  psychic  intlueuee  of  remorse,  conscience. 


THE  CAUSES  OF  INSANITY.  157 

longing  for  honio  iiiu'l  frii^nds,  and  the  too  slcict  and  often,  hypercrit- 
ical discipliiie  and  trcatniciit  devoid  oi'  ajiy  jndividiialization. 

The  iiiajoriiy  of  cases  of  insanity  oecni'  in  llic  first  and  scfond  years  of 
imprisonment,  and,  according'  to  J)eibruck,  13  pei-  cent,  more  anioii^  accidental 
(affect)  than  amon!;-  liabitual  ci'iniinais. 

The  cause  of  fliis  is  fduiid  in  flic  I'ciiioi'sc  and  panics  of  conscience  in 
the  former,  Avhilc  tlie  latter  remain  moi'aliy  blunted. 

IJiuing  tlie  later  years  of  imprisonment  tolerance  oecui's,  and  a  certain 
mental  equilibrium  is  established. 

There  has  been  nnudi  conf roN'ersy  concerninn'  the  influence  of  various 
kinds  of  punishmt-nt  (isolation  and  se,L;i-ci;at  ion).  Tlie  old  strict  I'ennsyl- 
vaiiian  isolation,  witli  absolute  silence  and  absence  of  all  stimuli  from  the 
external  Avorld,  is  to  blame  foi-  man>'  cases  of  insanity;  but  if  isolation  is 
humanely  carried  out, — i.e.,  if  consideration  is  had  for  the  physical  and  mental 
needs  of  the  prisoners, — then  it  has  no  more  injurious  iiiHuence  than  segrega- 
tion.    But  applied  to  a  case  of  developing  insanity,  it  hastens  the  outbreak. 

Nevertheless,  isolation  is  not  suited  for  every  prisoner.  For  persons  of 
very  limited  mental  poMer  that  require  the  stimuli  of  the  external  world;  for 
those  that  are  suspicious,  proud,  and  eccentric,  and  who,  even  in  their  ordinary 
life  were  not  regarded  as  quite  normal;  and  for  others  that  suffer  great  re- 
morse and  pangs  of  conscience,  it  is  dangerous  (Baer).  The  forms  of  prison 
insanity  are  those  that  occur  in  ordinary  life,  modified  by  the  peculiar  hygienic, 
social,  and  disciplinary  conditions  of  the  prison. 

Noteworthy  modified  forms  that  occur  in  accidental  criminals,  besides 
melancholia,  are  demonomania,  nostalgia  of  emotional  genesis  (pangs  of  eon- 
science),  hypochondria  (due  to  unhygienic  influences  of  prison  life),  and  a  form 
of  insanity  occurring  in  isolation  and  beginning  with  hallucinations  of  hearing. 
The  patients  hear  that  they  have  been  forgiven  and  the  period  of  imprison- 
ment is  over.  They  ask  querulously  to  be  discharged,  and  are  deluded  in  the 
belief— when  their  demands  are  refused — that  they  are  unjustly  detained. 
Delusions  of  persecution  develop.  At  the  beginning  of  the  disease  recovery 
takes  I'lace  cpiickly  if  the  prisoner  is  put  with  others;  for  the  disturbance  is 
one  that  is  due  to  isolation. 

In.  habitual  criminals,  who  are,  for  the  most  part,  organically  burdened, 
besides  weak-mindedness  and  impulsive  acts,  we  observe  moral  insanity,  epi- 
lepsy and  epileptoid  states,  and  forms  of  periodic  insanity;  and  not  infre- 
quently, under  the  pressure  of  imprisonment  and  discipline,  and-  as  a  result  of 
the  great  irritability  of  such  defective  individuals,  violent  states  of  maniacal 
excitement  with  maniacal  explosions  occur. 

2.  Individual  Predisposing  Causes. 
HeredHy. 

By. far  the  most  important  cause  of  insanity  is  transmissibility 

of  psychopathic  dispositions  or  cerebral  infirmities  by  way  of  heredity. 

.  The  fact  of  inheritance  of  psychic  peculiarities  and  disease  was 

known  even  to  Hippocrates.     It  is  but  one  of  the  manifestations  of  a 


158         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

biologic  law  that  plays  a  tremendous  part  in  the  organic  world,  and 
on  which  all  mental  advancement  of  tlio  Iniman  rnco  dopends. 

Next  to  tuberculosis  there  is  scarcely  any  fonu  of  disease  in  wlncli 
hereditj'  makes-itself  so  powerfully  felt  as  in  that  of  insanity;  but  there  is 
some  lack  of  harmony  in  the  estimates  of  the  frequency  with  which  it  occurs. 
Statistics  vary  in  ascribing  from  4  to  90  per  cent,  of  all  cases  to  heredity. 
Clearly,  where  there  is  such  a  considerable  dinVrcnco  there  can  be  no  law. 
The  cause  of  this  difference  can  only  lie  in  Uu-  various  niclhods  that  are 
applied  in  the  collection  of  statistics.  ]\lucli  depends  upon  tlie  classes  from 
Avliich  the  statistic  material  is  gathered.  In  aristocratic  classes,  in  groups  of 
individuals  cut  ofl'  from  general  intercourse  in  close  religious  societies  (Jews, 
sects,  Quakers)  where  inbreeding  takes  place,  the  percentage  of  heredity  is 
nuich  greater  than  in  an  interbreeding  population.  Too,  the  point  of  view  of 
difl'erent  statisticians  is  different.  Many  investigators  have  recognized  hered- 
ily  (nily  when  insanity  was  demonstrable  in  parents  (direct  similar  heredity). 
I3ut  so  narrow  a  conception  of  heredity  cannot  be  entertained. 

We  have  here  essentially  three  facts  to  consider : — 

(A)  Atavism. — The  physical  and  mental  organization  and  pecul- 
iarities may  be  transmitted  from  the  first  generation  to  the  third,  with- 
out making  their  appearance  in  the  intervening  generation;  tlius,  the 
life  and  health  history  of  the  grandparents  is  of  interest. 

(B)  Only  in  rare  cases  is  the  actual  disease  transmitted  l)y  hered- 
ity (congenital  insanity,  hereditary  syphilis)  ;  as  a  rule,  it  is  only  the 
disposition  to  it  that  is  transmitted.  Under  such  circumstances  actual 
disease  occurs  only  when  accessory  injurious  influences  make  them- 
selves felt. 

Thus,  we  mnst  investigate  the  health  history  of  the  blood-relations 
(uncles,  aunts,  cousins)  ;  and,  since  here  the  law  of  atavism  is  also 
operative,  any  diseases  that  have  affected  great  uncles  or  great  annts 
should  be  considered. 

(C)  It  is  only  exceptionally  that  one  and  the  same  disease  in  pro- 
genitors and  descendants  develops  as  a  result  of  hereditary  transmission 
of  abnormal  disposition.  On  the  contrary,  there  is  a  remarkable 
changeaJDleness  of  the  disease-pictures  that  has  almost  the  significance 
of  a  law  (pol3^morphism  or  transmutation). 

The  transmutations  are  innumerable.  The  most  various  neuroses 
and  psychoses  appear  in  families  affected  with  heredity,  side  by  side 
and  one  after  another,  through  generations;  and  they  teach  us  that 
from  a  biologico-etiologic  standpoint  they  are  branches  of  but  one 
and  the  same  pathologic  tree. 

The  varialnlity  of  hereditary  abnormal  conditions  makes  it  neces- 
sary to  Ijc  careful  in  deciding  to  what  states  and  forms  of  manifestation 


THE  CAUSES  OF  INSANITY.  159 

of  abnormal  nervous  life  the  hereditary  transmission  is  joined,  either 
directly  or  in  a  modified  form.. 

(a)  Without  doubt,  the  cases  in  which  psychoses  in  progenitors 
and  descendants  are  observed  (heredity)  are  of  this  nature.  In 
many  such  cases  the  psychosis  has  in  both  generations  the  same  form, 
and  breaks  out  nnder  the  influence  of  the  same  accessory  causes :  e.r/., 
the  puerperal  state  (similar  heredity). 

(i)  Of  similar  nature  is  the  phenomenon  of  suicide  occurring 
through  generations :  i.e.^  the  disposition  to  suicide,  which  is  almost 
always  a  symptom  of  melancholia  or  of  a  neuropathic  constitution 
incapable  of  enduring  the  severe  demands  of  life.  Especially  con- 
vincing are  the  cases  of  suicide  where  progenitor  and  descendant,  under 
similar  conditions  and  at  about  the  same  age,  kill  themselves.  There 
are  even  genealogic  tables  that  show  how  whole  tainted  families  have 
died  out  through  suicide. 

(c)  The  hereditary  influence  of  constitutional  neuropathy, 
whether  this  consist  of  mere  habitual  migraine,  or  hysteria,  neuras- 
thenia, or  epilepsy,^  is  unquestionable. 

The  injurious  hereditary  factor  may  express  itself  in  descendants 
merely  in  a  neuropathic  constitution,  in  a  neurosis,  or  in  some  psy- 
chosis up  to  the  degree  of  idiocy — the  severest  form  of  hereditary 
degeneracy. 

The  hereditary  influence  of  abnormal  character  in  predisposing 
to  insanity  has  been  demonstrated. 

Certain  enthusiasts,  perverted  individuals,  and  hypochondriacs 
have  not  only  very  frequently  mental  and  nervous  diseases  among  pro- 
genitors and  collateral  relatives,  but  also  neuropathic,  insane,  and 
even  idiotic  descendants. 

These  problematic  individuals,  who,  for  the  most  part,  from  child- 
hood np,  feel,  think,  and  act  differently  from  other  persons,  are  con- 
stantly in  danger  of  becoming  insane,  and  are  often  candidates  for 
the  degenerate  form  of  insanity  par  excellence — paranoia,  which  also 
especially  afl:ects  their  descendants. 

That  a  criminal  and  vicious  manner  of  life  stands  in  hereditary 
relation  to  insanity  is  shown  by  the  frequency  with  which  insanity  and 
other  neurotic  forms  of  degeneracy  occur  in  habitual  criminals  and  in 


^  Trousseau,  Medicinische  Klinik,  1867,  page  88.  Moreau  found,  among 
364  epileptics,  62  epileptic,  17  hysteric,  37  apoplectic,  and  38  insane  blood-rela- 
tions; 195  times,  convulsions,  consumption,  scrofula,  eclampsia,  asthma, 
drunkenness,  etc.,  in  the  parents  and  blood-relations.  ]\Iartin,  Annales 
medieo-psychologiques,  1878,  November,  proves  that  the  children  of  epileptics 
very  frequently  die  of  convulsions. 


IGO  GKNKÜAL   PATlloLOdY  AND  TllEKArV  OF  INSANITY. 

their  blood-relatious^  progenitors,  and  doscoiulants.  Nevertheless, 
crime  as  a  moral,  and  insanity  as  an  organic,  plicnomenou  remain 
opposites.  The  common  points  of  contact  lie  simply  in  the  fact  that 
insanity  may  occur  also  in  tlie  clinical  form  of  moral  depravity  (moral 
insanity),  and  is  often  erroneously  taken  for  criminality. 

Drunkenness  must  also  be  regarded  as  a  link  in  the  chain  of 
hereditary  predisposing  factors.  It  is  only  infrequently  that  similar 
inheritance  occurs  here;  it  is  usually  unlike,  in  so  far  as  the  degenerate 
progenitors,  as  a  result  of  alcoholic  excesses,  beget  children  that  enter 
the  world  idiotic,  hydrocephalic,  or  with  a  neuropathic  convulsive  con- 
stitution, and  soon  succumb  to  convulsions;  those  that  live  develop 
epilepsy,  hysteria,  mental  diseases,  and  the  severest  forms  of  psychic 
degeneration,  as  a  result  of  the  abnormal  constitution  of  the  nerve- 
centers. 

Thus,  Claret'  reports  the  case  of  a  drunkard  wlio  liad  1(!  cliildren,  15  of 
whom  died,  and  the  only  survivor  became  epih'ptic.  Acccirdiu;;'  to  Uarwin, 
the  families  of  drinkers  die  out  in  the  fourth  «iontMalion.  Murel  traces  the 
degeneration  as  follo\Ys: — ■ 

First  generation:   moral  depravity,  alcoholic  excesses. 

Second  generation:    drunkenness,  maniacal  attacks,  general  paralysis. 

Third  generation:    liypocliondria,  melancholia,  ta'diinii  vitrr,  murder. 

Fourth  generation:     imbecility,  idiocy,  extinction  of  the  family. 

But  the  fact  proved  by  Flemming,  Euer,  and  Demeaux  in  reported  cases 
is  wonderful — that  even  children  of  sober  parents,  when  begotten  at  tlie  time 
of  intoxication,  are  in  a  high  degree  disposed  to  insanity  and  ner\ous  diseases 
in  general;  this  fatal  influence  may  even  make  itself  felt  at  tlic  time  of  birth 
and  give  rise  to  congenital  ■\\cak-mindGdncss. 

Griesinger  calls  attention  to  the  fact  that  genius  is  sometimes 
associated  with  hereditary  idiocy.  Morcau  went  so  far  as  to  call 
genius  a  neurosis.  That  men  of  genius  not  infrequently  (Schopen- 
hauer's grandmother  and  uncle  were  weak-minded)  iiavc  insane  and 
mentally  defective  relatives,  and  beget  weak-minded  and  even  idiotic 
children,  is  unquestioned.  It  seems  as  if  a  generally  high  and  fine 
organization  of  the  nervous  elements  in  one  case,  under  the  influence 
of  esjDecially  favorable  conditions,  leads  to  higher  development; 
under  unfavorable  conditions,  to  mental  degeneration. 

Whether  close  blood-relatioi^ship  is  to  be  regarded  as  a  degenera- 
tive factor  is  still  a  matter  of  dispute^ ;  but  experiments  by  breeders  of 
animals,  who,  to  be  sure,  breed  from  only  the  best  animals,  as  well  as 


^According  to  Beauregard  (Annales  d'Hygiene,  1802,  page  22G),  from  17 
consanguineous  marriages  there  were  95  children,  among  Avhom  there  were  21 
idiots,  1  deaf-mute,  1  hunchback,  and  only  37  normal  individuals. 


THE  CA [TSKS .OK  INSANITY. 


IGl 


the  genealogy  of  the  I'ioleiiiies,  sjjeak  against  it.  It  is  possible  that  it 
remains  without  influence  so  long  as  the  individuals  concerned  are 
devoid  of  degenerate  elements;  hut,  if  this  is  not  the  case,  then  rapid 
degeneration  is  certain. 

According  to  Boudain'a  investigations,  in  mai-riages  of  blood-relations 
sterility  and  miscarriages  are  frequent,  and,  descendants  have  slight  power  of 
resistance,  and  are  afflicted  with  a  lymphatic  constitution,  with  commonly  a 
disposition  to  scrofula  and  tuberculosis.  Other  frequent  phenomena  under 
such  circumstances  are  monstrosities  (superfluous  fingers  and  toes,  club-foot, 
harelip,  etc.)  ;  albinism  (which  in  animals  maj'  be  produced  experimentally  by 
continued  union  of  individuals  of  the  same  fiuiiil}^)  ;  retinitis  pigmentosa 
(Liebreich) ;  congenital  deafness,  and  in  a  proportional  relation  to  the  degree 
of  blood-relationship  of  the  parents.  If  the  danger  of  begetting  a  deaf  child 
in  an  ordinary  marriage  is  reckoned  as  1,  then  the  danger  must  be  reckoned  as 
18  in  the  marriage  of  cousins,  37  in  the  marriage  of  uncles  and  nieces,  and  70 
in  the  marriage  of  nephews  and  aiuits,  while  direct  transmission  of  deafness  is 
rare  (Meniere).  Very  frequently  in  the  descendants  of  marriages  of  blood- 
relations  mental  diseases  and  epilepsy  occur  (Esquirol). 

The  significance  of  heredity  in  our  domain  becomes  especially 
clear  when  the  fate  of  families  that  have  been  subject  to  mental  disease 
is  followed  through  generations. 

The  following  genealogic  table  is  that  of  a  family  which  came 
under  mv  observation : — ■ 


First  Gkn- 

EKA'l  ION. 

Second  Geneka- 

TION. 

TJiiiED  Generation. 

Fourth    Generation. 

Fifth  Gen- 
eration. 

r 

1.  Child  of  first  daugh- 

? 

1. 

Daughter    in- j 
sane               i 

ter,  fate  unknown 

2.  Daughter  insane 

3.  Son — m  a  n  i  a,     de- 

mented 

None 
None 

Father  ~ 
insane 

■  ^ 

2. 

Daughter 
healthy 

r 
I 

7  healthy  children 

? 

^    1.  Son  insane,  suicide 

None 

3 

Daughter    in- 

2.  Daughter, demented 

3.  Daughter    afflicted 

None 

Daughter, 

r 

with  periodic  in- 

None 

> 

only         j 
child,  became 
insane 

4. 

Daughter 
healthy 

sanity 

2    sons,     history    un- 
known 

? 

5. 

Son  insane 

None 

— 

Mother 
healthy  ^ 

6. 

Son  insane 

: 

1.  Son  healthy 

2.  Son  insane 

3.  Daughter  healthy  < 

None 
Daughter 
insane 

- 

7. 

8 

Son  healthy 
Son  healthy 

3  healthy  children 
5  healthy  children 

163  GENERAL  PATHOLOGY  AND  TMEPvArY  OF  INSANITY. 

Of  these  37  individuals  descendants  from  insane  ancestors,  13  are  insane 
and  2-4  (?)  healthy,  though  reports  concerning  some  are  wanting  and  others 
of  them  are  still  very  young. 

Finally,  there  can  be  no  doubt  that  all  influences  that  weaken 
the  nervous  system  and  the  procreative  power  of  the  individual, 
whether  too  youthful  or  of  too  great  age,  previous  weakening  diseases 
(typhoid,  syphilis,  tuberculosis),  mercurial  cures,  alcoholic  excesses, 
over-exertion,  etc.,  may  give  rise  to  neuropathic  constitutions,  and 
thus  to  all  possible  nervous  diseases  in  descendants. 

A  glance  at  all  the  facts  mentioned  shows  that,  on  the  whole, 
insanity  is  a  manifestation  of  degeneration,  the  conditions  of  which  are 
to  be  sought  in  congenital  abnormal  disposition,  transmitted  in  the 
embr3'onic  elements,  as  an  expression  of  inherited  pathologic  conditions 
of  the  brain  of  progenitors,  or  of  alterations  of  the  brain  acquired  in 
the  course  of  life.  The  abnormal  disposition,  infirmity,  or  actual  dis- 
ease induced  by  any  of  these  factors  evinces,  according  to  the  biologic 
law  of  heredity,  a  strong  inclination  to  become  transmitted  in  some 
form  or  other  to  descendants. 

The  manner  of  transformation  in  the  course  of  hereditary  transmission 
and  -fehe  special  form  of  nervous  or  psychic  infirmity  are  dependent  upon  indi- 
vidual as  well  as  external  and  largely  accidental  conditions.  Science  has  not 
yet  succeeded  in  formulating  a  law. 

In  general,  it  may  be  said  that  when  two  tainted  individuals  beget  chil- 
dren, or  when,  also  to  the  bad  constitution  of  one  parent  unfavorable  injurious 
influences  (drunkenness  and  weakening  diseases)  are  added,  the  taint  in  de- 
scendants grows  more  decided;  and  with  continued  transmission  the  psycho- 
pathic degenerative  factor  induces  progressive  degeneration  to  the  most  severe 
form.  Out  of  neuropathies,  psychoses  develop,  at  first  benign  in  form,  having 
the  character  of  the  psychoneuroses;  then  arise  the  still  more  degenerate 
forms  of  circular,  periodic,  moral,  and  impulsive  insanity;  until  finally  idiocy 
results.  Then  Nature  obliterates  the  pathologic  family,  which  loses  physio- 
logic power  to  propagate  itself. 

On  the  other  hand,  regeneration  at  a  certain  stage  is  still  possible  by 
crossing  with  the  healthy  blood  of  an  intact  family,  or  under  the  influence  of 
favorable  circumstances.  The  forms  of  disease  then  become  progressively 
milder;  and,  if  the  crossing  is  continued,  the  degenerate  seed  may  disappear 
completely. 

A  congenital  disposition  may  also  arise  without  any  hereditary  influence. 
Thus,  anomalies  in  the  form  of  the  skull  and  in  the  development  of  the  brain 
may  result  from  a  rachitic  pelvis  in  the  mother  (Zuckerkandl)  ;  from  degen- 
erative development  of  the  brain  as  a  i-esult  of  fetal  brain  disease  (poren- 
cephaly) or  injury;  perhaps,  too,  from  emotional  disturbance  in  the  motlier 
during  pregnancy;  and  finally  as  a  result  of  the  parents  being  too  young  or 
too  old  ^Emminghaus). 


THE  CAUSES  OF  INSANITY.  163 

The  interesting  question  whether  there  is  such  a  tiling  as  a  clin- 
ical form  of  hereditary  insanity,  which  has  been  answered  in  the 
affirmative  by  Morel,  must  still  remain  open. 

In  my  experience,  the  hereditary  degenerative  factor  forms  ordy 
one  of  the  manifestations  of  degenerate  insanity  in  general  (vidö 
"Special  Pathology ''). 

With  reference  to  the  foregoing  question  it  is  necessary  to  eraplia- 
size  the  difference  that  exists  between  simple  hereditary  predispositioji, 
(latent  disposition)  and  hereditary  taint  (burden)  :  i.e,^  where  tlie  fac- 
tor of  heredity  in  the  psycho-physical  development  and  nature  of  the 
individual  exists  and  exerts  a  definite  and  burdening  influence.  In- 
sanity based  merely  upon  an  hereditary  predisposition  differs  in  no 
way  from  cases  that  are  not  hereditary,  except  that  in  the  former 
insanity  occurs  at  an  earlier  period  of  life, — its  outbreak  is  induced  by 
slight  accessory  causes,  is  more  sudden,  recovery  is  quicker,  and  the 
prognosis  better. 

In  the  cases  representing  transitional  stages  to  hereditary  degen- 
erate insanity  the  forms  of  dis^ease  become  more  grave,  more  organic, 
and  certain  features  of  degeneration — like  stupor,  impulsive  acts,  and 
periodicity — make  themselves  manifest. 

Neuropathic  Co7istitution. 

Next  to  hereditary  predisposition  the  most  important  predisposing 
factor  in  the  individual  is  that  peculiar  condition  of  the  nervous  sys- 
tem that  has  been  called  neuropathic,  the  essential  element  of  which 
lies  in  the  fact  that  the  equilibrium  of  the  functions  is  very  delicately 
established,  and  under  the  influence  of  slight  causes  is  lost;  and,  fur- 
ther, in  the  fact  that  reaction  to  irritation  of  any  kind  is  extremely 
intense  and  extensive,  quickly  leading  to  exhaustion. 

This  condition  of  "irritable  weakness"  makes  it  possible  for 
stimuli  to  exercise  an  influence  which  on  individuals  that  are  not  neu- 
ropathic would  exert  no  effect  at  all,  or  an  effect  of  less  intensity;  and 
thus  is  explained  the  readiness  with  which  disease  results  from  the 
slightest  injurious  influence. 

Such  a  neuropathic  constitution  is  congenital  or  acquired.  In  the  first 
case,  as  a  rule,  it  arises  upon  an  hereditary  basis,  and  is  the  functional  expres- 
sion of  beginning  degeneration  of  the  most  highly  organized  nervous  ele- 
ments. It  may,  however,  be  congenital  in  the  descendants  of  parents  in 
nowise  tainted,  and  it  is  then  the  result  of  weakening  influences  that  affect 
the  embrj'o  at  the  time  of  conception  (e.g.,  severe  diseases,  syphilis,  and  mer- 
curial cures  in  the  father)  ;  or  of  injurious  influences  exercising  their  effect 
during  fetal  life  (diseases,  disturbances  of  nutrition,  excesses;  on  the  part  of 
the  mother,  etc.).     Not  infrequently  the  neuropathic  constitution  is  acquired 


lü-l  GENERAL  IW  TIK^LOi  IN'  .WD  TIJEÜAPY  ÜF  INSANITY. 

as  a  result  of  severe  cxliausthij:^  diseases  like  typhoid,  frequent  and  difficult 
labors  and  the  puerperal  slate,  hcmorrhap;es,  sexual  excesses,  onanism,  and  as 
a  result  of  mental  and  ])hysical  over-exerlion  in  conneoUon  Avitli  emotional  dis- 
turbances. Too,  severe  acute  disease-  in  rlnliUuHul,  like  the  exanthemata  and 
cerebral  diseases,  may  induce  it. 

luliK  til  Inn. 

Next  to  his  braiu  organization;,  man  owes  most  to  tlie  nature  and 
iiKinncr  of  his  education  as  att'ecting  the  ijeculiarity  of  his  mental  char- 
Mc'ter.  Sometimes  organization  and  education  act  together  in  the  pro- 
duction of  psycliopathic  disj^osition ;  in  so  far  as  parents  transmit  to 
their  children,  not  only  by  way  of  heredity  an  unfortunate  organic  con- 
stitution, but  also,  tlirough  consequent  abnormal  passions,  defects  of 
morals,  and  force  of  bad  example  and  defective  education,  their  eccen- 
tricities and  moral  defects. 

Thus  may  arise  the  conditions  for  hysteria,  bypoclioiulria,  and 
inebriety. 

If  it  be  asked  what  peculiar  defects  of  education  are  apt  to  give  rise  to 
the  predisposition  to  insanity,  we  may  answer:  — 

(a J  Too  strict  treatment  of  an  extremely  impressionable  and  emotional 
child,  who  is  sensitive  and  so  much  in  need  of  loving  care.  If,  in  a  case  like 
this,  harshness  predominates,  then  not  only  is  the  development  of  proper  feel- 
ing prevented  from  its  incipiency,  but,  at  the  same  time,  a  foundation  is  laid 
for  painful  relations  with  the  world,  ending,  perhaps,  in  tadiuiii  rttcc  and  a 
retiring  character. 

(J)J  On  the  other  hand,  an  education  that  is  too  solicitous,  which  can 
deny  nothing,  and  excuses  everything,  and  thus  cultivates  obstinacy,  imbridled 
passions  and  emotions,  defective  self-control,  and  inability  to  practice  self- 
denial. 

A  mother's  darling  seldom  amounts  to  nuu-h.  Social  life  demands  self- 
control  and  submission  to  the  majority,  power  of  resistance  to  the  storms  of 
life,  and  resignation.  AMiere  these  qualities  are  wanting,  tlicrc  is  no  cscap 
ing  disappointments,  bitterness,  and  pain.  Sometimes  the  later  rough  school 
of  life  makes  up  for  defects  of  education,  and  forms  the  character;  but  this 
cannot  occur  without  great  trouble,  wliicli  tlu'catcns,  in  many  instances,  the 
mental  equilibrium. 

(c)  Too  early  awakening  and  strain  of  the  intellectual  powers  at  the 
cost  of  the  emotions  of  childish  simplicity  and  bodily  health.  This  cause 
makes  itself  doubly  felt  where  brilliant ^and  often  one-sided  capabilities,  as 
they  occur  in  neuropatliic  and  hereditarily  predisposed  children,  excite  the 
pride  of  parents  and  guardians,  and  lead  to  overstj-ain  of  the  mental  powers 
of  the  precocious  child.  It  is  only  rarely  that  such  premature  and  brilliant 
children  amount  to  much,  and  then  only  if  they  are  treated  like  hot-house 
plants.  In  the  best  case  they  develop  one-sidedly,  and  become  "partial 
geniuses"  with  weak  bodies.  Not  infrequently,  however,  especially  at  the 
time  of  puberty,  their  development  is  arrested,  and  they  nuike  no  furtlier 
advance. 


THE  CAUSES  OF  INSANITY.  1G5 

In  general,  the  cducaüon  of  eliildren  of  llie  higher  classes  must  bo  char- 
acterized as  defective.  All  too  early  does  the  struggle  for  existence  affect 
these  children  in  the  form  of  exorbitant  demands  in  school,  which  can  only  be 
satisfied  at  the  cost  of  sleep  and  physical  development. 

In  this  vv'ay  a  neuropathic  constitution  may  be  acquired,  and  thus  the 
foundation  laid  for  later  insanity.  No  less  dangerous  is  the  too  early  intro- 
duction of  children  into  the  social  circles  of  adults.  This  leads  to  early 
satiety,  to  anticipated  sensual  indulgences  and  excesses,  which  injure  physical 
and  mental  health. 

Accessory  Causes. 

1.  Psychic  Causes. 

Witlioiit  doubt  emotions  may  give  rise  to  insanity,  just  as  they  are 
occasional  causes  of  hysteria,  epilepsy,  chorea,  aphasia,  and  by  shock 
may  even  canse  fatal  jDaralysis  of  the  heart  and  respiration.  On  the 
other  hand,  occasionally  the  cure  of  mental  disease,  of  paralysis  of 
the  will,  and  conditions  of  aphasia,  may  be  similarly  induced.  The 
great  influence  exerted  on  the  vasomotor  and  motor  centers  by  affects 
at  least  makes  clear  the  power  of  such  psychic  movements. 

But  from  this  point  to  insanity  is  a  long  stej).  The  idea  of  the 
laity,  especially  of  dramatists  and  novelists  who  represent  insanity  as 
arising  out  of  poAverful  passions  and  affects  Avithout  anything  else,  is 
at  least  one-sided.  ISFevertheless  there  are  cases  in  which  violent 
affects,  for  the  most  part  fright,  have  immediately  induced  insanity 
(stupor,  primary  dementia,  mania)  ;  but,  as  in  analogous  cases  of 
epilepsy,  there  always  exists  in  such  cases  a  considerable  predisposi- 
tion (neuropathic,  principally  hereditary)  or  a  temporarily  increased 
excitability  of  the  brain  (menses,  puerperal  state).  The  shock-like 
psychic  influence  in  such  a  case  disturbs  the  vasomotor  innervation, 
and  consequently  the  circulation  and  nutrition  of  the  brain. 

As  a  rule,  the  psychosis  does  not  immediately  follow  the  etiologic 
influence,  and  there  is  often  a  longer  or  shorter  period  in  wliich  tlie 
individual  affected  seems  to  regain  his  psychic  equilibrium ;  but  later 
the  patient  begins  to  be  ill,  loses  weight,  and  suffers  with  disturbances 
of  digestion  and  menstruation,  with  anemia,  sleeplessness,  and  tubercu- 
losis. The  intermediate  factors  between  cause  and  effect  are  those 
disturbances  of  nutrition  that  finally  reach  the  psychic  organ. 

The  previous  existence  of  a  somatic  or  psychic  disposition  favors 
the  outbreak,  but  the  influence  of  the  psychic  element  in  undermining 
the  constitution  may  induce  insanit}^  Avithout  such  aid. 

This  is  easier  when  the  psychic  cause  acts  in  a  chronic  way :  e.g.j 
in  the  form  of  household  trouble. 


1G6    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Too,  in  cases  where  a  single  outbreak  of  emotional  excitement 
leads  to  insanity  after  weeks  or  months,  there  is  usually  a  coexistent 
predisposition;  or  the  shock  is  so  intense  and  sudden  that  the  ideas 
accompanying  the  affect  induce  neuralgias  or  become  fixed  imperative 
ideas.  Experie'iice  shows  that  it  is  almost  exclusively  depressive  emo- 
tions (death,  loss  of  fortune,  loss  of  honor,  etc.)  tliat  lead  to  insanity. 

The  causes  vary  with  the  sex  and  individuality.  In  women  they 
are  injury  of  honor  (rape),  or  the  slow,  and  therefore  more  injurious, 
influences  of  unhappy  love,  marriage,  jealousy,  or  the  sickness  or  deatli 
of  children.  In  men  imsuccessful  efforts,  loss  of  occupation,  injured 
pride,  and  financial  ruin  are  effectual. 

Not  infrequently  physical  maltreatment,  and  also  railroad  accidents,  are 
causes  of  mental  disease  (traimiatic  neurosis). 

Sometimes  mechanical  traumatic  influences  play  an  etiologic  role,  but, 
as  a  rule,  it  is  the  psj^chic  shock  associated  with  the  physical  injury  that 
exercises  the  decisive  influence. 

The  pathogenesis  is  psychic  through  the  painful  afTect  resulting  from 
maltreatment,  which  is  maintained  by  pain  following  the  injuiy,  by  anxiety 
about  the- possible  results,  by  the  feeling  of  injured  honor,  or  by  the  exciting 
influence  of  lawsuits,  etc.  (forms  of  melancholia,  hypochondriac  depression, 
hysteria,  etc.).  Or  the  origin  is  vasomotor,  due  to  vascular  spasm  or  vascular 
paralysis  resulting  from  the  fright.  Under  such  circumstances  Ave  observe 
forms  of  stupor,  primary  dementia,  melancholia  attonita,  and  acute  mania. 

Ca,ses  of  purely  mental  origin  are  such  as  occiu*  after  a  stupor. 

The  transitory  deliria,  mainly  accompanied  by  frightful  hallu- 
cinations that  occur  in  some  instances  where  the  eyes  are  merely 
closed,  in  patients  who  are.  shut  in  a  dark  room,  and  also  in  patients 
that  have  been  operated  upon  for  cataract  and  other  eye  diseases,  are 
mainly  due  to  the  effect  of  fright. 

In  my  experience  in  such  cases  we  have  to  do  with  individuals 
that  are  imbecile,  abnormally  excitable,  or  those  weakened  by  old  age, 
alcohol,  and  other  depressing  influences. 

Among  psychic  causes  of  insanity  must  also  be  reckoned  imitation 
(contagion),  like  the  well-known  cases  of  hysteria  and  hypochondria 
due  to  mental  contagion. 

There  is  always  in  such  cases  a  decided  predisposition,  whether  it  be 
hereditary  or  a  family  tendency,  or  like  social  conditions  (hunger,  religious 
and  political  excitement) ;  or,  as  Nasse  found,  the  strain  of  caring  for  insane 
patients  has  broken  the  physical  and  mental  strength  of  excited  relatives. 

If  predisposition  is  wanting,  association  -with  insane  patients  for  scien- 
tific or  humane  purposes  has  scarcely  any  efl'ect  at  all.  It  is  a  fact  that  those 
connected  Avith  asylums  seldom  become  insane,  and  then  it  is  usually  under 
conditions  that,  aside  from  the  peculiarity  of  occupation,  would  have  had  the 
same  effect;  but  for  those  that  are  tainted  the  calling  of  the  alienist  or 
attendant  is  dangerous. 


THE  CAUSES  OF  INSANITY.  1C7 

2.  Physical  Causes. 
Cerebral  Diseases. 

Meningitis. — Insanity  is  the  expression  of  disturbance  of  nutri- 
tion of  the  brain  cortex  which  may  go  even  to  the  extent  of  degenera- 
tion. 

Owing  to  the  anatomic  and  functional  relationship  of  the  blood- 
vessels of  the  pia  mater  and  the  cerebral  cortex,  it  is  evident  that 
hyperemia  and  tissue-changes  in  the  pia  may  induce  disturbances  of 
nutrition  in  the  brain  cortex,  and  thus  bring  about  insanity. 

Thus,  acute  leptomeningitis,  when  it  takes  a  chronic  form  and 
exudates  are  not  reabsorbed,  may  induce  disturbances  of  nutrition  and 
symptoms  of  irritation  in  the  cortex  (dementia  and  intercurrent 
mania).  Tuberculous  meningitis  not  infrequently  runs  a  subacute 
course  in  adults,  in  the  form  of  an  almost  afebrile  psychosis.  Too, 
pachymeningitis  interna  hemorrhagica  may  induce  psychic  disturb- 
ances (primary  progressive  dementia  with  general  ataxia,  paresis,  and 
intercurrent  maniacal  states  of  excitement,  epileptic  and  apoplectic 
attacks). 

Focal  Diseases  op  the  Brain. — The  anatomic  changes  lying  at 
the  foundation  of  mental  diseases  are  diifuse,  not  focal. 

Focal  diseases  of  the  brain,  when  they  do  not  affect  the  cortex,  may 
run  their  course  without  psychic  disturbance;  frequently  enough, 
however,  they  are  complicated  with  such  disturbance  when  they  are 
multiple  (sclerosis,  capillary  apoplexy),  or  when  by  pressure,  irrita- 
tion, secondary  degeneration  of  the  vessels,  edema,  etc.,  they  induce 
circulatory  and  nutritional  disturbance  in  the  cortex,  or  when  they 
cause  atrophy  of  a  part  of  the  brain  with  its  overlying  cortex.  In 
such  cases  the  disease-picture  is,  on  the  whole,  that  of  progressive 
dementia  with  paralysis,  with  occasional  states  of  excitement  caused 
by  irritation  and  disturbance  of  the  circulation. 

Among  diseases  of  the  brain  falling  in  this  category  are  to  be 
mentioned:    cerebral  apoplexy^;    atheroma  of  the  cerebral  arteries. 


^  Rochoux,  "Eecherclies  sur  I'EnceiJliale."  In  these  cases  there  may  be 
isolated  large  apoplectic  foci,  or  miliary  multiple  capillary  hemorrhages.  Clin- 
ically there  is  progressive  dementia  with  focal  paralyses.  Intercurrent  states 
of  psychic  excitement,  delirium,  hallucinations,  fear,  and  epileptic  attacks 
occur.  Sometimes  there  is  cure  of  the  apoplectic  focus  with  consecutive  brain 
atrophy  and  stationary  mental  weakness. 


IGS  GEXEKAL  PATITOLOCY  AND  TIlET^ArY  OF  INSANITY. 

with  multiple  euccplialitic   loci  of  softoning^;    multiple   sclerosis-; 
tumors^;  cysticerci  and  eehinococci.'* 

Etiologically  a  very  important  group  is  made  up  of  head  injuries. 
In  the  pathogenesis  of  this  "traumatic  insanity"  chronic  mcningitic 
and  encephalitic  processes  play  a  very  important  role.  They  are  some- 
times the  direct  result  of  irritation  which  the  trauma  causes;  sometimes 
they  are  due  to  inflammations  that  have  spread  from  circumscribed 
injuries  to  the  slaiU  or  brain  (apoplectic  foci,  brain  abscesses).  Occa- 
sionally constantly  repeated  attacks  of  congestion  of  a  brain  whose 
vascular  tone  is  damaged  induce  the  changes. 

The  psychoses  that  occur  under  such  circumstances  have  in  tlie  main  a 
jj:rave  idiopathic  character;  are  complicated  often  with  motor,  vasomotor,  and 
sensory  disturbances;    and,  for  tlie  most  part,  have  an  unfavorable  i)rognosis. 

They  follow  immediately  upon  the  traxima  or  develop  after  weeks, 
months,  or  years. 

In  the  first  case,  following  upon  the  symptoms  of  concussion  come  symp- 
toms of  brain  irritation  (headache,  dizziness,  feelings  of  anxiety,  hallucina- 
tions, narrow  pupils,  and  grinding  of  the  teeth),  with  motor  (disturbances  of 
co-ordination,  circumscribed  paralysis)  and  sensory  disturbances  (cutaneous 
and  sensorial  hyperesthesia).  The  latter  soon  pass  away,  but  with  the  con- 
tinuance of  the  motor  disturbances  and  occasional  outbursts  of  excitement 
(fear,  hallucinations)  a  great  reduction  of  the  mental  fimctions  takes  place. 

In  some  cases  there  is  recovery  (Iluguenin,  Wille),  but  usually  there  is 
some  mental  weakness  remaining,  and  it  may  even  go  to  the  extreme  degree 
uf  progressive  dementia  with  great  irritability  (chronic  periencephalomen- 
ingitis). 

When  insanity  does  not  immediately  follow  u])on  head  injury,  the  rela- 
tion between  the  two  is  shown  by  a  longer  or  shoiter  stage  of  cerebral  irrita- 
bility as  a  result  of  diffuse  cortical  distuibance  (periencephalitie  processes, 
hardening  of  the  ganglion-cells,  increase  of  glia  tissue,  Durand-Fardel  cell 
infiltration),  induced  by  transformation  of  extravasations,  cysts,  irritation  by 
splinters  of  bone,  etc.;  or  the  same  thing  arises  from  frequently  repeated 
attacks  of  congestion  to  which  the  weakened  brain  is  disposed  b}'  the  trauma. 


^Ti(U  "Dementia  Senilis"    ("Special  Pathology"). 

*  Here  there  is  constantly  and  very  early  mental  weakness  with  childish 
weeping.  In  its  course,  frequently  intercurrent  deep  melancholia  with  tcrdiinn 
ritcp,  and  sometimes  also  delusions  of  persecution  and  gi-eat  delirium;  terminal 
dementia. 

^  Here  there  is  progi'essive  dementia  with  general  paralysis  and  focal 
s-sinptoms  (paralysis,  convulsions).  Intercurrent  maniacal  states  are  possible. 
The  tumor  may  also  lead  to  the  disease-picture  of  dementia  paralytica  (Gazette 
des  Höpitaux,  1857,  page  123). 

*  Cysticerci  usually  found  in  the  cortex;  eehinococci,  in  the  ventricles. 
Symptoms  of  progressive  dementia  with  intercurrent  apoplectic  and  epileptic 
attacks  occur. 


THE  CAUSES  OF  INS  AX  IT  Y.  10!) 

TliP  syiiiptonis  of  tliis  prodi'cjinal  stage  in  the  psyfViie  spliere  arc  intense 
irritability,  change  of  character  for  the  worse,  as  a  result  of  which  the  out- 
break of  insanity  is  hastened;  in  cases  in  which  dementia  paralytica  develops 
later  the  prodromal  symptoms  consist  of  signs  of  brain  exhaustion  (weakness 
of  memory,  mental  apathy).  With  these  psychic  symptoms  we  observe  very 
frequently  headache,  dizziness,  complaint  of  inhibition  of  tliouglil,  optic  and 
acoustic  hyperesthesia,  spontaneous  congestion  or  congestion  resulting  from 
slight  causes,  and  with  an  evident  increase  of  all  the  symptoms  of  brain  irri- 
tation. 

These  psychoses  are  forms  of  mental  disease  that  closely  resemble  de- 
mentia paralytica;  or  angry  manias  with  sudden  explosions  and  violent  conges- 
tions recurring  periodically,  with  a  tennination  in  dementia  with  brutal 
irritability;  or  epileptic  insanity  (usually  large  scars  and  adhes^ion  of  the 
membranes  to  the  skull). 

A  head  injury,  however,  may  also  be  effectual,  not  so  much  in  actually 
causing  insanity  as  in  lowering  the  resistive  power  of  the  brain  and  thus 
inducing  a  predisposition  for  the  accidental  development  of  insanity.  Clear 
understanding  of  how  trauma  acts  to  induce  weakness  is  wanting;  but  without 
doubt  it  exerts  its  primary  effect  on  vasomotor  innervation  and  reduces  the 
resistive  power  of  the  vasomotor  nervous  system.  This  acquired  disposition 
diie  to  traumatism  usually  expresses  itself  in  a  tendency  to  congestion,  intol- 
erance of  alcohol  and.  heat,  and  also  frequently  in  a  marked  tendency  to 
physical  and  mental  exhaustion  and  great  emotional  irritability.  In  such 
cases,  it  is  usually  influences  that  reduce  vasomotor  innervation  (affects, 
drunkenness,  heatstroke)  that  indvice  the  psychosis.  This  may  appear  in 
various  forms  (mania,  delusions  of  persecution,  and  general  paralysis). 

The  picture  of  an  idiopathic  psychosis  is  always  in  such  cases  more  or 
less  easily  recognized,  and,  along  Avith  the  psychic  symptoms,  congestive  symp- 
toms, complaints  of  headache,  and  dizziness  are  noted. 

Following  the  cases  of  insanity  due  to  head  injury  come  those  due 
to  the  extension  of  inflammation  from  the  temporal  bone  (caries, 
otitis  interna)  to  the  meninges  and  brain.  In  these  cases,  too,  we  have 
to  deal  with  severe  idiopathic  conditions  usually  ending  in  death 
(manias). 

Insanity  may  also  be  due  to  caloric  influences  (insolation  and 
great  heat  from  furnaces),  and  the  form  of  disease  is  usually  acute 
delirium  or  progressive  dementia  with  great  irritability  and  inter- 
current outbreaks  of  anxious  excitement ;  or  also  dementia  paralytica. 
The  immediate  causes  are  probably  hyperemia  induced  by  the  heat, 
as  a  result  of  which  inflammatory  processes  in  the  brain  and  meninges 
are  induced  (cloudy  swelling  as  a  forerunner  of  parenchymatous 
encephalitis — Arndt;  pachymeningitis  and  leptomeningitis).  The 
prodromal  symptoms  of  insanity  due  to  caloric  influences  are  those 
of  brain  hyperemia  (dull  headache,  pressure  in  the  head,  irritability, 
mental  languor  and  dullness,  sleeplessness). 


170    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Diseases  of  the  Spinal  Cord. 

In  the  course  of  tabes  psychic  disturbances  are  not  infrequently 
observed.'  Besides  elementary  psychic  depression,  and  "dementia 
tabica^'  which  sometimes  accompanies  tabes  from  its  beginning  (West- 
phal,  Simon),  as  a  cause  of  which  Simon  demonstrated  the  existence 
of  sclerosis  of  the  white  substance,  there  are  not  infrequently  psychoses 
that  develop  as  the  final  phenomenon  of  tabes,  and  then  are  usually  in 
the  form  of  dementia  (cerebral  atrophy,  pachymeningitis — -Simon), 
dementia  paralytica,  delusions  of  persecution,  and  melancholia.  The 
manner  of  origin  is  probably  one  depending  upon  the  tabetic  process 
and  disturbances  of  vasomotor  innervation,  and  in  case  of  dementia 
paralytica  the  identity  of  the  decisive  cause  (syphilis). 

Affections  of  the  Peripheral  Nerves. 

Analogous  to  cases  of  tetanus  and  ej^ilepsy  following  peripheral 
nerve  injury,  psychoses  may  also  develop  as  a  result  of  the  direct  reflex 
irritation  of  the  cerebral  cortex,  or  through  vasomotor  reflex  influ- 
ence and  consequent  disturbances  of  the  circulation. 

In  addition  to  the  older  cases  reported  by  Jordens,  Zeller,  and 
Griesinger,  Koppe  has  shown  that,  as  a  result  of  a  traumatic  neuralgia 
of  the  fifth  and  the  occipital  nerves,  reflex  psychoses  may  develop,  and 
that  without  any  injury  of  the  brain.  In  some  cases  recovery  was 
brought  about  by  excision  of  the  scar.  Another  very  instructive  case 
is  that  of  Wendt,  in  which  a  gunshot  injury  of  the  left  auriculo- 
temporal nerve,  with  occasional  recrudescence  of  pain  in  the  course  of 
this  nerve,  was  followed  by  attacks  of  epileptoid  delirium. 

As  a  rule,  a  neuropsychopathic  constitution  is  present  and  ren- 
ders the  vulnerable  cerebral  cortex  obnoxious  to  joerij^heral  irritation. 
Too,  the  weakening  effect  upon  the  brain  in  general,  and  especially 
upon  the  vasomotor  innervation,  of  the  trauma  that  induced  the  neu- 
ralgia is  to  be  regarded  as  pathogenic  in  such  a  case. 

In  a  few  cases  the  factor  of  psychic  shock,  with  the  injury,  must 
be  given  weight  in  the  etiology. 

The  clinical  demonstration  of  the  traumatic-neuralgic  relation- 
ship in  such  cases  is  found  in  the  history  of  the  origin;  the  aura-like 
return  of  the  neuralgia  before  and  during  the  psychic  attack;  the 
possibility,  sometimes  present,  of  inducing  the  attack  by  provoking  the 
neuralgia,  as  by  pressure;  and  finally  the  success  of  treatment  by  such 
procedures  as  excision  of  the  scar,  or  local  anesthesia.  The  outbreak 
of  insanity  follows  shortly  after  the  injury;  the  disease-picture  is  not 


THE  CAUSES  OF  INSANITY.  171 

uniform,  but  most  frequcniiy  is  ciiiicr  epiieptoid,  hystero-cpiieptic, 
or  hypochondriac-melancholic. 

Operative  Procedures. 

Aside  from  the  psychoses  observed  after  operations  on  the  eye, 
others  after  various  operative  procedures,  especially  castration,  have 
been  frequently  observed.  The  pathogenesis  is  various.  Besides  nea- 
ropathic  constitution  and  neuroses  as  predisposing  conditions,  where 
the  neurosis  may  be  independent  or  stand  in  relation  with  the  disease 
that  requires  the  operation,  other  important  factors  are  the  mental 
excitement  which  often  precedes  and  accompanies  operations ;  mechan- 
ical shock;  loss  of  blood;  the  influence  of  chloroform;  and  the  toxic 
influence  of  certain  drugs,  such  as  iodoform,  during  the  after-treat- 
ment; and,  in  cases  of  castration,  the  climacteric  thus  induced  {vide 
"Psychoses  of  the  Climacteric^''). 

The  psychoses  that  occur  after  operations  are  usually  early  and  tran- 
sitory. Maniacal  states  are  decidedly  the  most  frequent  (Gucci).  The  prog- 
nosis is  dubious.  Another  gi'oup  of  cases  is  made  up  of  states  of  delusional 
insanity,  seemingly  the  exi^ression  of  iodoform  intoxication  (Jll),  or  due  to  the 
effect  of  chloroform  (Salvage). 

Those  that  are  most  familiar  and  important  are  the  cases  of  insanity 
occurring  in  Avomen  after  ovariotomy,  which  ai'e  to  be  regarded  as  psychoses 
of  the  artificially  induced  climacteric.  Melancholic  disease-pictures  predomi- 
nate here;  sometimes  acute  manias  are  observed  (Gaillard).  The  correspond- 
ing operation  in  men  may  induce  melancholia,  as  is  shown  by  cases  reported  by 
Gucci  and  Weiss. 

Wunderlieh  describes  under  the  term  delirium  traumaticum  or  nervosum  a 
transitory  insanity  following  painful  operations  or  injuries,  felons,  etc.  It 
occurs  from  one  to  three  days  after  the  operation  or  injury.  The  pa^tient 
becomes  talkative  and  excited;  after  sleepless  or  dream-disturbed  nights  the 
eyes  become  bright,  the  face  flushed,  the  ideas  confused.  Eestlessness  in- 
creases ;  the  patient  no  longer  feels  any  pain,  begins  to  act  wildly,  sings,  cries, 
and  tears  off  the  bandages.  At  the  same  time  the  pulse  is  quiet  and  no  fever 
is  present.  After  a  few  days  sleep  becomes  deeper  and  longer,  and  the  patient 
awakes  knowing  nothing  of  what  has  taken  place.  Sometimes  death  occurs 
from  exhaustion  in  from  thi'ee  to  five  days. 

General  Neuroses. 

Insanity  not  infrequently  accompanies  or  follows  general  neu- 
roses. 

Choeea.  Minor. — In  this  disease  there  are  almost  always  elementary 
psychic  disturbances,  such  as  irritability,  apathy,  mental  indiflference,  forget- 
fulness,  and  confusion;  frequently  also  hallucinations  of  sight,  and  sometimes 
even  well-marked  mental  diseases  like  mania,  active  melancholia,  and  demono- 


172  GENERAL  rATIlOLOCV  AND  THERAPY  OF  INSANITY. 

mania  of  porsooution,  wliicli  iirobahly  liave  the  siyiiirK-aiu-o  of  inanition 
psychoses  due  to  exhaustion  following  upon  the  greatly  increased  nuisciilar 
action  ajid  lack  of  sleep. 

There  are  some  reported  cases  wl\ich  indicate  that  psychoses  may  occur 
rarely  in  Basedow's  disease. 

Dr.  Hirschl,  in  a  noteworthy  work,  lias  collect cil  all  the  cases  reported  of 
Base<low's  disease  in  literature  since  18112,  43  in  all.  and  has  increased  tiiat 
number  by  6  of  his  own  eases. 

As  common  causes  of  the  tAVo  complicated  diseases  the  author  linds 
heredity  and  psychic  trauma. 

The  anatomic  substratum  of  the  psychosis  is  probably  cerebral  hyperemia 
due  to  dilatation  of  the  vessels  following  paralysis  of  the  vascular  center  in 
the  medulla. 

After  separating  the  cases  in  which  the  relation  with  Ba,sedow's  disease 
was  highly  questionable  (alcoholic  delirium,  foUe  du  doute,  hysteropathic  and 
febiile  delirium,  hallucinatory  insanity,  dementia  paralytica),  the  remaining 
cases  were  mainly  states  of  mania,  much  less  frequently  melancholia  with 
pronounced  feelings  of  anxiety.  Maniacal  conditions  cori'espond  with  the  de- 
generate forms,  with  predominance  of  an  irritable  st^te  of  feeling.  The 
jirognosis  is  unfavorable.  In  49  cases  of  the  psychoses  in  Basedow's  disease 
there  were  only  6  recoveries,  and  18  cases  ended  fatally. 

As  an  elementa.ry  and  almost  typic  mental  disturbance  accompanying 
Basedow's  disease,  Hirschl  observed  abnormal  gaiety  and  irritability.  In  pro- 
nounced cases  the  psychic  picture  "lay  midway  between  health  and  maniacal 
exaltation  on  a  degenerate  foundation." 

Ball  has  also  noted  the  freqiienc)^  of  mental  disturbance  in 
paralysis  agitans. 

Besides  the  well-known  mental  weakness  usual  in  tlie  course  of  this 
disease,  which  is  probably  a  manifestation  of  premature  senility,  Ball  foimd 
in  the  majority  of  his  patients  elementary  psychic  anomalies  like  irritation; 
and  frequently  also  psychoses,  in  the  main  melancholia  with  hallucinations 
and  impulses  to  suicide,  usually  occurring  intermittently  and  simultaneously 
with  exacerbations  of  the  motor  neurosis.  Parent  describes  a  case  which  gives 
the  impression  of  a  senile  dementia  with  occasional  attacks  of  hallucinatory 
excitement.  In  general  in  these  cases  premature  senility  seems  to  play  the 
most  important  etiologic  role. 

Ps\X'hoses,  partly  transitory  and  partly  lasting,  in  association 
with  hysteria  and  h3'pochondria,  are  very  frequent.  Almost  always  in 
such  cases  hereditary  taint  is  demonstrable,  and  the  psychosis  then 
forms  the  end  of  a  progressive  disease-process  affecting  the  nerve- 
centers  more  and  more  widely  {vide  "Special  Pathology ^^). 

Epilepsy. — Seldom  does  an  epileptic  remain  free  from  mental 
disturbance  throughout  his  life.  Besides  ordinär}'  elementary  and 
frequent  transitory  disturbances  of  the  mind,  the  mental  powers  fre- 
quently undergo  a  deep,  lasting,  and  usually  progressive  deterioration 


THE  CAUÖEÖ  UJ.<'  JN.SANITY.  ]  7;] 

(according  to  Eeynolds,  Gl  per  cent.),  in  wliich  at  first  tJie  cliaractor 
and  ethic  splicro,  find  finally  inlelligenco,  siifTnr  (monlnl  degenera- 
tion).   This  deteriuraiion  niciy  progress  to  deepest  dementia. 

The  manner  of  origin  of  jiiental  disturbance  in  epilepsy  is  not 
clear.  The  ex2}lanation  mnst  be  sought  in  hereditary  or  acquired  lira  in 
disturbances  that  lie  at  the  basis  of  epilepsy,  and  which  in  iheii-  fur- 
ther progress  affect  the  psychic  organ  itself. 

Much  less  effectual  are  the  general  disturbances  of  tijc  circulation 
due  to  epileptic  attacks,  as  is  shown  by  the  fact  that  the  vertiginous 
form  of  epilepsy  is  much  more  dangerous  for  the  mind  tlian  the  con- 
vulsive form. 

Congenital  ej^ilepsy  and  that  beginning  before  puberty  not  only 
interfere  with  the  development  of  the  brain,  but  usually  in  the  course 
of  life  lead  to  dementia.  The  violence  of  attacks  seems  less  dan- 
gerous to  integrity  of  mental  power  than  their  frequent  occurrence. 
Females  are  more  endangered  by  it  than  males  (vide  "  Special  Pathol- 
ogy," "Epileptic  Insanity"). 

Acute  Constitutional  Diseases.'^ 

Acute  diseases,  especially  those  in  which  a  high  temperature  is 
quickly  reached,  with  a  sudden  critical  fall,  are  not  unimportant 
causes  of  disturbances  of  the  mental  functions.  In  such  cases  ele- 
mentary disturbances  of  the  mind  in  the  form  of  somnolence,  stupor 
(disturbance  of  consciousness),  illusions  (apperception),  hallucina- 
tions (central),  rapidity  of  ideation,  disturbances  of  association,  con- 
fusion, deliria  (intellect),  are  common.  This  symj)tomatic  or  sympa- 
thetic excitement  of  the  cerebral  cortex  either  limits  itself  to  such 
disturbances  or  progresses  to  general  and  complex  involvement  of  the 
psychic  organ — delirium.  The  disease-pictures  classed  under  the  head 
of  delirium  differ  in  general  from  those  that  we  are  accustomed  to 
classify  as  insanity  in  general,  by  their  transitory  character,  by  their 
deep  involvement  of  the  sensorium,  the  incoherence  and  confusion  of 
ideation,  and  the  predominating  involvement  of  the  senses  in  the  form 
of  hallucinations.  These  states  of  delirium,  owing  to  the  irregular 
irritation  of  the  organ  of  thought  by  inadequate  stimuli,  and  the  sup- 
pression of  the  higher  faculties  of  attention  and  reflection,  present  the 


^Compare  the  excellent  monograph  of  Kräpelin,  "Ueber  den  Einfluss 
acuter  Krankheiten  anf  die  Entstehung  von  Geisterkrankheiten,"  with  ex- 
haustive literature  (Archiv  für  Psychiatrie,  Bd.  xi  und  xii),  whose  conclusions 
are  summarized  in  the  text. 


174    GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY, 

characteristics  of  hallucinatory  confusion,  and,  therefore,  out  of  this 
condition  systematized  delusions,  with  lasting  anomalies  of  feeling, 
or  fixed  delusions  with  total  change  of  personality,  are  not  easily 
developed.  However,  transition  is  easy,  and  the  origin  of  chronic  and 
independent  states  of  insanity  out  of  the  delirium  of  acute  diseases  is 
not  infrequent. 

In  acute  diseases  delirium  occurs,  for  the  most  part,  at  two  stages 
of  their  course:  at  the  height  of  the  disease-process  and  during  the 
period  of  its  subsidence.  The  delirium  of  the  acme,  or  febrile  delirium 
in  its  narrower  sense,  occurs  especially  in  acute  infectious  diseases,  and 
is  apparently  due  to  disturbances  of  nutrition  and  circulation,  Avhich 
arc  induced  by  the  febrile  process  in  the  brain  and  the  body  at  large, 
especially  where  there  is  very  high  temperature  (favorable  effect  on 
the  delirium  of  antipyretic  measures).  The  most  important  dis- 
turbances of  this  kind,  at  the  beginning  of  febrile  processes,  are 
increase  of  the  heart's  action,  hyperemia  of  the  cortex,  increased  oxida- 
tion of  the  albuminous  tissue-elements  with  insufficient  substitution; 
and,  in  the  course  of  the  disease,  the  venous  hyperemia  due  to  func- 
tional weakness  and  degeneration  of  the  heart-muscle,  thrombosis  of 
capillaries,  stasis,  edema,  and  the  accumulation  of  the  waste-products 
of  metabolism  in  the  brain  as  a  result  of  their  insirfficient  removal. 
Besides,  there  is  the  direct  toxic  and  ferment-like  effect  of  the  infec- 
tious material  circulating  in  the  blood,  which,  independently  of  the 
fever,  may  induce  toxic  delirium :  e.g.^  in  the  stage  of  incubation  when 
no  fever  has  occurred. 

The  delirium  of  the  acme  is  usually  of  a  muttering  character; 
but  it  may  also  appear  in  the  form  of  anxious  excitement,  with  corre- 
sponding hallucinations  and  delusions  of  persecution,  or  as  a  furibund 
delirium. 

The  delirium  that  occurs  in  the  stage  of  subsidence  of  a  febrile 
disease  (from  collapse,  inanition,  asthenia,  or  exhaustion)  depends 
upon  anemia  and  grave  disturbances  of  nutrition  in  the  cortex.  It 
occurs  with  especial  frequency  in  diseases  that  have  a  critical  fall  of 
temperature,  like  pneumonia,  and  the  acute  exanthemata,  where  sud- 
denly the  heart-muscle,  that  has  previously  been  stimulated  by  the 
fever,  loses  its  energy,  and  the  cortex,  exhausted  by  overstimiilation 
during  the  stage  of  fever,  and  which  physiologically  requires  an 
abundant  blood-supply,  is  suddenly  deprived  of  the  required  amount 
of  blood. 

Other  disease-processes  that  are  accompanied  by  acute  and  pro- 
fuse loss  of  the  fluids  of  the  body  (elujlera)  are  also  often  followed  by 
such  states  of  inanition-delirium. 


TIIE  CAU8ES  OF  INSANITY.  175 

Besides  cardiac  weakness  and  loss  of  fluid,  according  to  Kräpelin, 
we  must  also  consider  the  chemic  influence  and  the  tissue-changing 
effect  of  infectious  material  and  waste-products  of  tissue-change  on 
the  brain,  especially  in  typhoid  aijd  malarial  diseases.  Too,  hered- 
itary and  other  pre-existing  dispositions,  which  are  of  small  importance 
in  febrile  delirium,  here  play  a  part. 

In  contrast  with  febrile  delirium,  Kräpelin  explains  the  develop- 
ment of  more  numerous  symptoms,  the  deeper  involvement  of  the 
personality,  even  to  the  extent  of  a  detailed  system  of  delusions,  the 
longer  duration,  and  less  favorable  prognosis,  with  the  not  infrequent 
termination  in  a  chronic  psychosis,  by  the  niore  profound  and  lasting 
changes  in  the  central  organ.  These  cases  of  inanition-delirium  are 
clinically  expressed  in  acute  desultory  elementary  disturbances  (hallu- 
cinations, delirium  with  indifferent  or  anxious  content,  attacks  of 
anxiety,  etc.),  or  as  protracted  and  more  complicated  states  of  melan- 
cholic, maniacal,  or  hallucinatory  confusion;  and  thus  they  represent 
transitions  to  actual  and  independent  psychoses. 

The  development  of  actual  psychoses  out  of  acute  diseases — i.e., 
those  that  develop  during  febrile  or  infectious  processes — may  follow 
upon  the  delirium  of  the  acme,  or  arise  during  the  stage  of  subsidence ; 
or  they  may  develop  spontaneously  in  the  later  stages  of  convalescence. 

The  psychoses  that  develop  at  the  acme  probably  stand  in  relation 
to  destructive  tissue-change,  grave  disturbances  of  the  circulation 
(thrombosis,  pigment  embolism),  capillary  hemorrhages  following 
upon  acute  degeneration  of  the  vessel-walls,  as  well  as  to  the  paren- 
chymatous irritative  changes  that  may  even  go  to  the  extent  of  inflam- 
mation. 

The  psychoses  that  arise  in  the  period  of  subsidence  are  due  to 
the  slow  and  difficult  re-establishment  of  the  nutrition  and  circulation 
of  the  brain;  the  obstruction  to  the  removal  from  the  brain  of  waste- 
products;  the  anatomic  changes  induced  by  the  febrile  process  and 
continued  beyond  its  subsidence ;  and,  finally,  to  disturbed  nutrition  of 
the  brain  resulting  from  tissue-changes  and  complications  in  the  vege- 
tative organs. 

Finally,  acute  febrile  diseases,  owing  to  their  weakening  influence 
on  the  brain,  may  leave  behind  them  a  disposition  to  mental  disease, 
by  virtue  of  which  emotional  disturbances,  mental  strain,  indulgence 
in  alcohol,  or  other  injurious  influences  may  cause  insanity. 

Among  the  acute  diseases,  typhoid,  pneumonia,  and  intermittent 
fever  play  especially  important  roles. 

Typhoid. — In  the  prodromal  stages  and  with  the  initial  fever  a  delirium 
pecui-s,  probably  of  toxic  origin,  that  disappears,  for  the  most  part,  during 


17G  CENERAL  rATIlOLOCY  AND  TIIEUAPY  OF  JiNSAMTY. 

the  course  of  the  disease.  These  are  cases  of  severe  infection,  with  a  mortal- 
ity as  high  as  GLö  per  cent.  Tlie  delirium  begins  with  frightful  luilUuinations 
of  siglit  and  hearinjjf,  and  during  its  course  there  are  forms  of  liallucinatory 
anxious  melancholia  with  fear  of  dcatli,  reactive  impulses  to  suicide  and 
murder,  delusions  of  persecution,  and  often  delusions  of  sin. 

The  febrile  delirium  at  the  height  of  the  disease  is  due  to  fever,  infective, 
poisons,  disturbances  of  the  circulalion,  parenchymatous  degenerations,  and 
consumption  of  the  nerve-tissue,  as  well  as  to  other  complications.  The 
fundamental  picture  is  one  of  stupor  extending  to  sopor,  due  to  hyperemia, 
I'dema,  increase  of  watery  fluids  (Jiuiil)  in  the  cranium,  and  increase  of  intra- 
cranial pressure.  Upon  this  basis  there  are  develoi^ed  illusional  and  hal- 
lucinatory states  of  confusion  witli  ilight  of  ideas,  and  not  iiifrcquontly  also 
with  i)S3'chomotor  s\ui]i(<inis  of  initation  (typliomania )  ;  so  that  llio  (.liseasc- 
picture  resembles  the  manical  type. 

The  prognosis  of  these  cases  of  febrile  (.lelirium  is  not  unfavorable.  Fre- 
quently they  are  protracted  a.s  a  result  of  complicating  diseases  of  the 
vegetative  organs,  especially  pneumonia,  decubitus,  pyemia,  and  venous  stasis 
in  the  brain  with  exudation  of  white  blood-corpuscles  (Duke  Carl  Theodore). 

In  about  one-third  of  the  cases  tlie  mental  disturbance  lasts  beyond  the 
fever,  and  it  may  continue  months  or  years.  As  a  residumn  of  the  dcliriiun, 
some  delusions  remain,  accompanied  by  hallucinations  and  an  anxious,  irri- 
table state  of  feeling.  The  patients  become  mentally  dull  and  confused  (acute 
dementia)  as  a  result  of  consumption  of  the  nerve-tissue — acute  brain  atrophy 
(deposits  of  pigment  in  the  cortex — Hofi'mann;    loss  of  fat — Buhl). 

The  acute  psychic  disturbances  diu-ing  convalescence  from  typhoid 
Kräpelin  refers  to  anemia,  faulty  composition  of  the  blood,  and  overloading 
of  it  with  products  of  retrograde  metabolism;  the  chronic  cases,  to  fatty  and 
pigmentary  degeneration  and  acute  brain  atrophy. 

There  are  four  forms: — 

1.  Quiet  delirium  lasting  from  a  few  days  to  a  week.  The  prognosis  is 
favorable.     Delusions  of  grandeur  are  remarkably  frequent. 

2.  States  of  maniacal  confusion  with  delusions  of  grandeur  and  fre- 
quently hallucinations,  even  to  an  intense  degree  of  mania.  Recovery  takes 
place  usually  in  the  first  month;  one-half  the  cases  recover  within  the  first 
year.  After  this  time  they  become  incurable.  Less  frequent  conditions  are 
those  of  agitated  melancholia  with  great  confusion  and  visual  and  auditory 
hallucinations. 

3.  Quiet,  even  stuporous,  mclancliolia  witii  delusions:  the  most  fi'equent 
form.  Moroseness,  irritability,  and  delusions  of  persecution  and  sin  develop, 
and  in  30  per  cent,  there  are  also  hallucinations.  There  are  great  exhaustion, 
loss  of  flesh,  and  mental  weakness.  The  cases  last  months.  In  65  per  cent, 
recovery  takes  place.  Transitions  to  mania  and  delusional  insanity,  Avith 
final  ending  in  mental  weakness,  are  not  infrequent. 

4.  Acute  dementia.  The  patients  become  demented,  stupid,  weep  child- 
ishly, and  are  greatly  exhausted  mentally  and  physically.  The  course  of  the 
disease  is  slow.  In  6G  per  cent,  it  lasts  more  than  a  year;  50  per  cent,  of  the 
cases  are  incurable. 

Variola. — In  this  disease,  also,  in  the  prodromal  stage,  there  are  some- 
times developed  conditions  of  excited  and  even  furibimd  confusion,  which  may 
last  into  the  stage  of  suppuration,  or  may  even  pass  on  into  chronic  mental 


THE  (;A USES  OF  INSANITY.  177 

disturl)ance.  These  are  due  to  toxic  influence.  'I'iie  delirium  at  tlie  Ijciglil  of 
the  disease  Kriipelin  attributes  to  congestive  hyperemia,  infective  processes, 
grave  disturbances  of  tissue-metabolism,  and  violent  pain  due  to  the  inflam- 
matory process  affecting  the  skin  and  mucous  membranes.  In  the  stage 
of  subsidence  of  the  fever,  asthenic  and  hallucinatory  delirious  states  of 
short  duration  occui',  in  connection  with  the  japid  fall  of  temperature  below 
normal  and  profuse  serous  exudation  in  the  pustules.  Chronic  psychoses  fol- 
loAving  variola  are  infiequent.  Krii]jelin  found  only  eight  cases  in  literature, 
which  lasted  from  a  few  months  to  a  year.  They  occurred  in  the  beginning 
of  the  third  week  of  the  disease,  and  usually  took  the  form  of  anxious  melan- 
cholia.    Acute  maniacal  delirious  pictures  were  also  observed. 

Scarlet  fever,  measles,  and  erysipelas  about  the  head  are  also 
rarely  causes  of  mental  disturbance.  In  such  cases  the  anomaly  lasts  from  a 
few  weeks  to  a  few  months.     The  prognosis  is  usually  favorable. 

Intermittent  Fever. — Two-thirds  of  the  oases  of  this  kind  reported  in 
literature  Avere  due  to  influence  of  the  malarial  intoxication,  and  took  the 
form  of  an  intermittent  insanity,  lasting  hours  or  daj's,  occurring  instead  of 
the  attacks  of  fever,  with  a  quotidian,  and  less  frequently  ä  tertian  or 
quartan,  type,  and  usually  with  perfect  intermißsion. 

These  attacks  of  the  "psychosis  typica"  existed  at  the  beginning  instead 
of  the  intermittent  febrile  attacks  -(intermittens  larvata),  and  not  infre- 
quently without  any  accompanying  symptom  of  fever.  The  most  frequent 
form  of  this  malarial  psychosis  Kräpelin  found  to  be  agitated  melancholic 
delusional  states  with  violent  fear,  frightful  hallucinations,  and  impulses  to 
suicide  and  homicide — on  the  whole,  very  similar  to  the  delirious  states  of 
excitement  of  epileptics.  Sometimes  tetanic  and  epileptiform  convulsions  ac- 
companied the  paroxysm,  which  usually  ended  after  a  few  hours  of  sleep,  from 
which  the  patient  awoke  with  no  memory,  or,  at  least,  a  very  imperfect  one, 
of  the  attack.  States  of  maniacal  exaltation  with  confused  delusions  of 
grandeur,  and  quiet  melancholic  depression  with  vague  feelings  of  fear  and 
hallucinations  of  hearing,  as  Avell  as  states  of  apathetic  confusion  and  pro- 
noimced  stupor,  are  less  frequent.  Another  way  in  which  the  psychosis  de- 
velops (as  a  rule,  a  state  of  maniacal  exaltation)  is  by  gradual  substitution 
for  the  attacks  of  fever. 

Finally,  chronic  insanity  may  develop  on  the  basis  of  malarial  cachexia 
as  an  expression  of  anemia  and  melanemia  (pigmentary  embolism  of  the 
cortex — Griesinger),  and  continue  months  or  7>^ears.  In  literature  such  cases 
are  reported  mainly  as  manifested  in  states  of  stupor  and  acute  dementia;  less 
frequently,  in  maniacal  and  melancholic  delirious  confusion  with  hallucinations. 
With  sustaining  treatment  the  prognosis  is  not  unfavorable. 

Acute  Articular  Rheumatism. — The  older  physicians  (Sydenham  and 
others)  were  acquainted  with  the  fact  that  severe  cerebral  symptoms,  even 
with  a  fatal  ending,  may  complicate  acute  articiüar  rheumatism.  Whether 
this  was  to  be  explained  by  the  height  of  the  fever,  by  toxic  influences,  or  by 
inflammatory,  hyperemic,  meningeal,  or  endocarditic  complications,  seemed,  and 
still  seems,  questionable. 

Kräpelin  divides  these  cases  of  acute  rheumatic  cerebral  affection  into 
two  groups.  The  first  group  presents  severe  cerebral  symptoms,  lasting 
hours  or  weeks,  that  are  due  to  hyperemia  of  the  nerve-centers,  with  even 
transudation,  or  meningitis  arising  from  embolic  pyemic  processes.     In  70  per 


178         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

cent,  of  the  casps  death  occurred.  The  second  frroiip  is  characterized  by 
delirious  states  developed  with  a  rapid  rise  of  temperature  to  hyperp^yrexia, 
M-hich  soon  pass  into  collapse  and  usually  end  fatally  (rheumatic  apoplexy, 
typhoid  rheumatism).  The  autopsies  were  principally  negative:  so  that  we 
are  justified  in  thinking  of  a  toxemic  process  due  to  a  rheumatic  ferment 
exerting  a  pyrdgenous,  pernicious  influence.  Besides,  in  the  first  or  second 
week  of  the  disease  ordinary  febrile  dcliriMin  may  develop:  in  rrl  per  cent,  of 
the  cases  with  collapse  and  death,  with  liypciemia  of  the  meninges  and  l)r:iin. 
From  the  third  to  tiie  sixth  week,  as  results  of  the  fever  and  severe  compii- 
eations  (endocarditis,  pericarditis,  pneunvonia),  and  not  infrequently  asso- 
ciated with  a  relapse  of  the  rheumatic  process,  mental  disturbances  are 
observed  which  subside  with  the  disappearance  of  the  fever:  but,  when  the 
organism  has  been  greatly  weakened,  the  mental  trouble  may  be  more  pro- 
tracted, Kriipelin  observed,  under  such  circumstances,  hallucinatory  delirium 
\\ilh  states  of  anxiety  lasting  as  long  as  three  weeks;  cases  of  agitated 
melancholic  delirium  of  several  months'  duration,  sometimes  with  convulsions, 
chorea,  and  attacks  of  vertigo:  further,  protracted  hallucinatory  confusion, 
with  a  predominating  anxious  coloring;  and,  finallj^,  alternating  maniacal  and 
stuporous  conditions.  Astlienic  psychoses  with  a  protracted  cour.se  are  not 
of  so  very  infrequent  occurrence,  especially  in  those  that  are  already  weak  or 
exhausted  by  the  disease,  and  the  psychosis  is  then  induced  by  slight  accidental 
causes. 

A  group  of  cases  that  are  especially  frequent  and  that  belong  here  con- 
sists of  states  of  melancholic  or  maniacal  excitement  with  great  confusion, 
mental  exhaustion,  and  hallucinations,  with  frequent  transitions  to  stupor,  92 
per  cent,  of  which  recover.  In  another  group  belong  cases  of  melancholic  de- 
pression with  transition  to  hallucinatory  delirium  or  stuporous  states, 
frequently  associated  with  severe  cerebral  motor  disturbances.  All  such 
patients  recovered  after  a  few  months. 

The  occasional  alternation  of  the  atfection  of  tlic  joints  and  the  psychosis 
that  has  been  observed,  Kriipelin  explains  as  accidental;  and  he  calls  at- 
tention to  the  fact  that  the  disappearance  of  the  joint  affection  is  more 
apparent  than  real,  for,  with  the  development  of  the  psycliosis,  the  inflamma- 
tory pain  may  be  no  longer  felt  or  expressed.  On  tlie  other  hand,  the 
psychosis  may  be  temporarily  overcome  during  a  relapse  of  the  joint  afl'ection 
as  a  result  of  the  influence  of  the  fever,  which  increases  the  amount  of  blood 
going  to  the  exhausted  and  anemic  brain.  Complicating  chorea  was  observed 
in  19  per  cent,  of  all  asthenic  psyclioses. 

PoLY?s'ErBiTis. — In  this  disease,  which  is  largely  due  to  infection,  psy- 
choses (hallucinatory  confusion)  have  also  been  observed,  especially  at  the 
height  of  the  disease.  However,  psychoses  are  not  frequent  when  the  cases  of 
polyneuritis  in  alcoholics  are  left  out  of  account.  Korsakow  has  reported 
sixteen  non-alcoholic  cases,  and  attributes  them  to  the  influence  of  a  toxin. 
He  calls  this,  in  his  opinion  typic,  psychosis,  "Cerebropathia  psychica  tox- 
aemica"  (general  confusion,  with  or  without  hallucinations,  with  amnesia  for 
latest  events). 

PxEUJroKiA. — In  this  disease,  weakened  constitutional  states,  especially 
those  due  to  drink,  are  decidedly  influential.  Febrile  delirium  at  the  height  of 
the  disease  occurs  in  severe  cases,  especially  with  pneumonia  of  the  apex  and  a 
weakened   constitution.     It   is   due   to    cerebral   congestion;     very   rarely   to 


THE  CAUSES  OF  TNSAMTY.  1 79 

meningitis.  It  begins  from  tlic  fourth  to  tlic  si.vtii  day  of  tlie  disease,  lasting, 
for  the  most  part,  only  a  few  days,  and  is  very  dangerous  (35.4  per  cent,  mor- 
tality). In  these  cases  muttering  delirium,  as  well  as  attacks  of  delirious 
mania,  are  observed. 

In  patients  predisposed  or  weakened  by  drink  the  delirium  may  outlast 
the  period  of  fever  (profound  disturbance  of  cerebral  nutrition,  weakened 
action  of  the  heart,  insuflicient  decai'bonizutiou  of  tlie  blood  due  to  pnhnonary 
hepatization). 

Not  infrequently  other  psychoses  arc  developed  in  the  form  of  anxious, 
confused  excitement  with  delusions  of  persecution ;  or  with  delusions  of 
grandeur  and  joyful  feeling,  multitudinous  hallucinations,  flight  of  ideas,  and 
impulse  to  constant  movement,  lasting  weeks  or  months,  and  finally  ending 
favorably. 

The  delirium  that  occurs  with  the  subsidence  of  fever  is  that  of  collapse 
due  to  cardiac  weakness  and  the  consequent  venous  stasis,  and  cerebral  edema. 
This  is  especially  likely  to  occur  in  those  that,  before  the  outbreak  of  the  dis- 
ease, were  weak,  particularly  individuals  reduced  as  a  result  of  drink.  It 
manifests  itself  in  states  of  excitement  with  liallucinatory  confusion,  flight  of 
ideas,  sleeplessness,  great  prostration,  and  subnormal  temperature.  The  hal- 
lucinations and  delusions  are,  for  the  most  part,  frightful  in  character — of  per- 
secution, poison,  and  sin.  However,  delusions  of  grandeur  do  occur.  The 
duration  of  these  cases  is  usually  only  a  few  days,  but  they  may  be  pro- 
tracted weeks  or  months;  finally,  with  rest  and  sufficient  sleep,  recovery  takes 
place  in  84  per  cent,  of  the  cases. 

Influenza.- — The  epidemics  of  the  last  few  years  have  shown  that  this 
general  disease  is  relatively  very  frequently  followed  by  nervous  and  mental 
disttu-bances.  These  depend  upon  functional  exhaustion  and  inanition  of  the 
central  nervous  system,  and  are  probably  to  be  explained  as  the  resvilt  of 
severe  disturbances  of  nutrition  due  to  a  toxin.  Besides  states  of  intense 
general  neurasthenia,  Kirn  observed  mainly  states  of  asthenic  delirium,  in 
some  instances  reaching  the  intensity  of  hallucinatory  confusion.  These  cases 
began  from  the  fourth  to  the  eighth  day  after  the  subsidence  of  fever,  and 
usually  in  from  three  to  six  weeks  recovery  occurred.  Infrequently  they 
passed  into  chronic  delusional  insanity,  and  less  frequently  ended  fatally. 
Exceptionally  he  observed  also  melancholia  of  exhaustion  Avith  great  disturb- 
ance of  sleep  and- great  loss  of  Aveight.  These  cases  usually  recovered  in 
from  six  to  eight  weeks.  Infrequently  (six  times  in  fifty-four  cases)  the 
psychosis  developing  after  influenza  took  the  form  of  mania  laevis. 

The  psychoses  after  influenza  observed  by  Kräpelin  were  depressive 
states  on  a  neurasthenic  foundation,  sometimes  resembling  melancholia,  some- 
times hallucinatory  insanity,  and  also  halkicinatorj-  confusion  dependent  upon 
states  of  collapse  and  inanition. 

Cholera. — Besides  the  occasional  stuporous  and  comatose  conditions, 
and  states  resembling  acute  delirium,  occurring  during  the  typhoid  stage  and 
the  stage  of  reaction,  Kräpelin  has  collected  from  literature  19  cases  of  mental 
disturbance  occurring  in  the  period  of  convalescence,  which  were  due  to  intense 
disturbance^  of  cerebral  nutrition.  There  were  transitory  states  of  excite- 
ment Avith  great  confusion,  melancholic  conditions  Avith  delusions  and  hal- 
lucinations of  several  Aveeks'  duration,  and  stuporous  states.  In  these  cases 
the  prognosis  is  entirely  favorable. 


ISO       tir:xEn.\T.  I'atiioi.ogy  and  TiiF,n.\i'Y  of  ins;amtv. 

Chronic  Consiitutional  Diseases. 

Anemia. — The  pathogenic  foundation  of  a  great  number  of  men- 
tal diseases  is  anemia,  when  this  is  a  ksting  condition  and  more  or 
less  constitutional  in  nature.  Just  as  the  anemic  individual  is  more 
susceptible  to  disease  in  general,  so  is  he  also  to  mental  disease ;  his 
susceptibility  to  injurious  influences  is  greater,  especially  to  those 
operating  through  tlie  vasomotor  and  emotional  spheres.  Anemia  in 
these  cases  constitutes  an  important  predisposition;  and  it  intensifies 
the  significance  of  any  pre-existing  predisposition  when  it  is  super- 
added. It  may  also  form  the  anatomic  substratum  of  the  actual 
disease. 

Chronic  anemia  gives  rise  to  mental  depression,  irritability,  and 
mental  indift'crence,  and  incapacitates,  even  to  the  degree  of  stupor. 
In  such  cases  mental  exertion  soon  leads  to  exhaustion ;  venous  hyper- 
emia due  to  uncompensated  valvular  disease  may  have  an  analogous 
effect. 

The  psychoses  that  develop  upon  such  a  foundation  are  simple 
melancholia  or  mania,  or,  where  there  is  a  predisposition,  forms  of 
stuporous  melancholia,  primary  dementia,  furious  mania,  and  even 
acute  delirium. 

The  general  idea  conveyed  by  the  term  "anemia"  is,  as  St-hiile  justly 
remarks,  unsatisfactory,  and  the  notion  how,  as  a  result  of  it,  tlie  distmbance 
of  nutrition  of  the  ganglion-cells  of  the  cortex  arises  is  very  incomplete 
(changes  in  vasomotor  innervation,  the  rapidity  of  the  flow  of  blood,  the 
blood-pressure  in  diffusion,  fatty  degeneration  of  the  vascular  walls  and  the 
cardiac  muscles,  especially  in  pernicious  anemia). 

The  causes  of  anemia,  are  various.  Loss  of  blood,  acute  and  cluouif; 
exhausting  diseases,  inanition,  prolonged  lactation,  frequent  childbearing, 
distxirbing  emotions,  sleeplessness,  severe  diseases  of  the  digestive  organs,  dis- 
eases peculiar  to  women,  cldorosis,  development  at  the  time  of  puberty,  sexual 
excesses,  etc.,  are  the  most  important  causal  elements  of  anemia.  It  should 
also  be  remembered  that  in* tainted  individuals,  especially  tliose  of  the  female 
sex,  constitutional  anemia  arising  at  the  time  of  puberty  and  continuing  in 
spite  of  all  treatment  is  a  very  common  manifestation,  and  it  must  be  looked 
upon  as  a  symptom  of  a  deep  neurotic  affection  trophic  in  nature. 

Anemia  that  has  arisen  acutely  as  a  result  of  loss  of  blood  or  fever, 
according  to  my  experience,  induces  mental  distiu-bances  only  in  those  that 
are  otherwise  weakened  or  predisposed.  The  mental  trouble  is  then  manifested 
in  stupor,  primary  dementia,  acute  maniacal  states,  or  more  frequently  melan- 
cholic conditions  with  intense  anxiety  and  multitudinous  hallucinations,  which 
are  almost  exclusively  confined  to  the  visual  sense.  The  intense  effect  of  the 
acute  loss  of  blood  on  those  that  are  already  weak  is  explained  by  the  results 
of  bleeding  in  insane  patients,  Avho  quickly  pass,  as  a  result  of  bleeding,  from 
maniacal  excitement  to   stupor,  or  after  a  short  period  of  quiet,  present  a 


"■j'lnc  ('Aijsi':s  OF  insais'I'I'v.  181 

graver  picture  of  tlie   original  mental  disturbance.     Even   the  recurrence   of 
profuse  menses  during  mental  disease  may  have  such  an  effect. 

Pulmonary  Tuberculosis. — The  etiologic  significance  of  pul- 
monary tuberculosis  in  its  relation  to  the  origin  of  insanity,  as  shown 
by  Hagen's  statistic  investigations,  is  much  less  than  was  formerly 
supposed.  More  frequently  tuberculosis  develops  in  patients  already 
suffering  with  insanity. 

The  comfortable,  careless  feeling  of  these  patients  and  tlieir  self-decep- 
tion concerning  the  nature  of  their  malady  are  well  known. 

Nevertheless,  in  some  cases  they  become  melancholic,  and  this  is  to  be 
attributed  to  the  lung  disease  which  operates  to  consume  and  deteriorate  the 
blood;  and  if  the  patient  lives  long  enough,  it  leads  to  mental  weakness,  de- 
pendent upon  the  gradual  brain  atrophy  and  an  edema  of  the  brain  that  is  not 
infrequently  found. 

Skae  and  Clouston  find  peculiar  features  in  this  form  of  melancholia 
(phthisic  insanity).  They  emphasize  the  suspicious  feeling,  apathy,  motive- 
less irritability,  with  occasional  outbreaks  of  angry  violence.  During  the  final 
stages  of  pulmonary  phthisis,  inanition-delirium  may  occur,  just  as  in  those 
that  are  exhausted,  dying,  or  starving,  etc.  It  has  a  muttering  character 
chiefly,  and  is  usually  made  up  of  pleasant  ideas  and  hallucinations,  though 
those  of  frightful  content  with  a  corresponding  reaction  are  not  excluded. 

Syphilis. — Syphilis  may  lead  to  insanity  in  various  ways,  both 
by  a  dyscrasia  and  by  localizations  in  the  brain  in  the  form  of  simple 
inflammatory  and  specific  changes.  The  importance  of  the  latter 
makes  it  necessary  to  describe  them  particularly  in  the  section  on 
special  pathology  {vide  "Cerebral  Lues"). 

Here  we  have  in  mind  only  those  psychoses  that  are  induced  by  the 
dyscrasia  as  such,  by  disturbed  nutrition  of  the  brain  resulting  from  syphilitic 
chlorosis.  What  has  been  said  concerning  the  significance  of  constitutional 
anemia  holds  true  for  this  special  form.  The  syphilitic  dyscrasia  has  a  weak- 
ening, predisposing  influence  upon  the  brain,  and  it  may,  as  such,  or  with 
additional  help  of  other  slight  accessory  injurious  influences  (emotions, 
trauma  capitis,  alcoholic  excesses,  etc.)  lead  to  insanity.  Thus,  Jolly  and 
Emminghaus  saw  cases  of  transitory  angry  mania  in  syphilities  where  the 
attacks  were  brought  on  by  slight  accessory  causes. 

Chronic  psychoses,  especially  melancholia  with  delusions  of  sin,  and 
syphilophobia  are  more  frequent;  also  severe  brutal  manias  with  sudden  out- 
break, with  fi'equently  a  rapid  termination  in  dementia. 

Chronic  Local  Diseases. 

Impressions  from  the  most  distant  organs  are  constantly  carried 
to  the  brain  by  the  sympathetic  nerves,  and  the  quality  of  these  impres- 
sions has  a  very  peculiar  influence  upon  the  state  of  feeling.  In 
this  it  is  worthy  of  note  how  varied  the  influence  of  the  different 
organs  is  (the  well-known  euphoria  of  the  consumptive  and  tabetic 


1S2  GENERAL  PATHOLOGY  AND    111  I'.llAl'Y  OF  IXSAM  TV. 

in  contrast  with  the  depro^^sion  and  hypochondriac  nudancholic 
states  associated  with  genital  and  intestinal  diseases).  Aside  from  this 
inflnence  upon  the  feelings  as  the  foundation  of  mental  activity  and 
sensihility,  diseases  of  the  vegetative  organs  may  act  similarly  by 
inducing  concl'ete  sensations  through  rotiex  transference  of  excitation 
in  the  vegetative  nerve-centers,  and  thus  disturb  the  circulation  in  the 
brain.  Besides  this  nervous  mechanism,  this  eh'ect  nuiy  also  be  induced 
mechanically  (heart  disease),  and  Jinally  diseases  of  the  organs  as  a 
result  of  disturbance  in  the  process  of  blood-formation  nuiy,  as  a  result 
of  inhil)ition  or  increased  secretions,  change  the  blood,  the  nourisher 
of  the  hi'ain.  ebeinically. 

Gastro-txtesttnat,  Diseases. — It  is  certain  tliat  acuto.  and  even  more 
frequently  chronic-,  s-astvic  catarrh  not  only  inflnence  the  state  of  feeling,  but 
also  often  induce  psychoses  that  usually  take  on  the  character  of  melancholia 
with  hypochondriac  coloring.  But  in  such  eases  more  exact  diagnosis  and 
examination  of  pathogenesis  are  required  before  the  assumption  of  causation 
in  indefinite  pathologic  conditions,  such  as  hemorrhoids,  portal  obstruction, 
enlargement  of  the  liver,  etc.,  or  accidenial  findings,  such  as  abnormal  posi- 
tion of  the  intestines,  which  were  formerly  (8cliröder  Van  der  Kolk),  and  still 
recently  have  been,  regarded  of  etiologic  significance,  is  justifiable. 

In  such  cases  the  pathogenesis  is  not  perfectly  clear.  Schule  ("Hand- 
book," page  275)  calls  attention  to  the  direct  neurotic  relation  in  which  the 
vertebral  vascular  area  (emotional  sphere?)  of  the  brain  stands  to  the  abdom- 
inal viscera  through  the  inferior  cervical  ganglia  with  the  splanchnic  nerves,  as 
well  as  the  nerves  arising  directly  from  the  liver.  Besides,  there  is  the 
venous  and  probably  vaso-paralytic  hyperemia  of  the  digestive  organs  that 
exerts  an  injurioius  influence  by  causing  anemia  and  directly  reducing  the 
nutrition  of  the  brain,  and  indirectly  the  injury  of  the  brain  due  to  distin-bed 
absorption  in  the  catarrhal  digestive  tract  aflfeeted  with  venous  hyperemia. 
The  obstipation  always  present  in  such  cases  increases  still  more-the  intensity 
of  the  catarrh,  and  thus  helps  to  interfere  with  the  circulation.  Too,  we 
should  think  of  the  possibility  that  the  blood  becomes  toxic  as  a  result  of 
acetone  and  hydrosulphuric  acid  absorbed  from  the  intestines.  In  manj' 
cases  of  this  nature,  however,  no  ga.stric  catarrh  is  present,  but  there  is  a 
neiirasthenia  gastrica  (vagus  neurosis),  the  precursor  or  symptom  of  a  uni- 
versal nfeurasthenia,  which  apparently  induces  the  )>sychosis  in  a  direct 
neurotic  way. 

In  literature  there  are  cases  in  which  irritation  of  the  intestines  due  to 
worms  induced  refle.x  psychoses  that  were  cured  by  the  use  of  anthelmintics. 
In  most  cases  roundworms  and  sometimes  tapeworms  were  recognized  as  the 
cause.  The  former  were  thought  to  induce  aciite  maniacal  states  of  excite- 
ment. In  cases  of  tapeworm  we  should  rather  think  of  the  distiu'bance  of 
nutrition  than  of  sympathetic  reflex  irritation  as  a  cause.  Oxyuris  may  lead 
indirectly  to  insanity,  in  that  it  induces  onanism,  and  this  leads  to  mental 
disease.  On  the  Avhole,  insanity  due  to  worms  is  an  infrequent  manifestation. 
and,  when  it  does  occur,  it  is  most  frequent  in  children,  and  then  in  those  with 
neuropathic  constitution. 


THE  CAUSES  OF  INSANITY.  1B3 

Heart  Disease. — Aside  from  ulcerative  endocarditis,  which  occasionally 
leads  to  cerebral  embolism  and  apoplectic  dementia,  we  have  here  to  consider 
valvular  lesions  and  compensatory  hypertrophy  of  the  cardiac  mascles.  Tiiese 
conditions  may  affect  the  mental  sphere  secondarily,  as  a  result  of  active 
fluxions  and  defective  compensation  through  venous  hyperemia  of  the  brain 
(anxiety),  lungs,  and  vegetative  organs  (catarrh,  anemia).  On  the  other  hand, 
there  is  a  possibility  (Karrer,  Guislain)  -that  cardiac  lesions  (hypertrophy) 
may  arise  secondarily  as  a  result  of  chronic  states  of  anxious  excitement, 
since  these  states  of  mind  induce  a  continued  increase  of  cardiac  activity; 
likewise,  fatty  degeneration  and  atrophy  of  the  heart  may  develop  in  the 
course  of  psychoses  and  lead  to  marasmus.  The  etiologic  significance  of  heart 
diseases  in  their  relation  to  the  origin  of  insanity  has  been  largely  over- 
estimated. 

Karrer  found,  in  autopsies  of  the  insane  at  Erlangen,  that  26  per  cent, 
were  afflicted  with  cardiac  anomalies,  and  the  sane  examined  postmortem  in 
the  pathologic  institute  presented  but  25  per  cent.:    a  very  small  difference. 

Mildner  and  others  found  that,  where  cardiac  defects  are  influential, 
hypertrophy  of  the  left  ventricle  and  insufficiency  of  the  aortic  valves  induce 
mainly  states  of  excitement  of  a  maniacal  nature,  while  hypertrophy  of  the 
right  ventricle  induces  melancholia;  at  the  same  time,  Mildner's  cases  of 
mania  seem  to  be  largely  eases  of  agitated  melancholia.  At  the  conclusion  of 
an  article  which  sheds  much  light  upon  this  difficult  and  complicated  question, 
Witkov.'ski  concludes  that,  with  the  excejjtion  of  insufficiency  of  the  aortic 
valves,  heart  disease  in  the  insane  is  associated  with  peculiar  unrest  and  in- 
stability, feeling  of  pressure,  expressions  of  which  are  largely  impulsive  in 
character  and  not  infrequently  become  intensified  to  excessive  violence  toward 
self  and  others. 

DISEASES  OF  THE  KiDNEYS. — From  his  own  and  the  experience  of  others 
Hagen  recites  numerous  examples  of  insanity  (not  merely  coma  and  delirium) 
in  the  course  of  clii-onic  nephritis.  In  most  cases  the  mental  disturbance  was 
manifested  in  melancholic  states  with  delusions  of  persecution  and  poisoning. 
In  one  case  there  was  recovery.  In  the  others  death  occurred  as  a  result  of 
the  fundamental  disease.  Foiu-  other  cases  of  chronic  degeneration  of  the 
kidney  with  mental  disturbance  were  reported,  but  in  these  cases  the  etiology 
was  not  clear,  and  they  were  complicated  by  the  climacteric,  pneumonia,  alco- 
holism, and  meningeal  hemorrhage. 

Hagen  looks  for  the  pathogenic  connection  between  diseases  of  the  kid- 
neys and  insanity  in  acute  or  chronic  uremia.  A  recent  work  by  Auerbach 
supports  Hagen's  observations  in  showing  that  mental  disturbance  (usually 
melancholic)  associated  with  disease  of  the  kidneys  is  referable  to  the  reten- 
tion of  waste-products  (uremia),  and  disappears  wäth  the  removal  of  the 
cause. 

Diseases  of  the  Female  Sexual  Organs. — The  influence  of  this  class 
of  diseases  should  not  be  underestimated.  Changes  in  the  texture  and  position 
of  the  uterus  play  here  the  principal  role,  when  they  have  induced  chronic 
inflammatory  and  irritative  tissue-changes  (flexions,  versions,  descent,  and  pro- 
lapsus). 

In  none  of  these  cases  do  emotional  and  especially  nervous  anomalies  fail 
to  occur.  Next  in  importance  in  an  etiologic  sense  come  the  neuralgic,  hyper- 
esthetic  affections  of  the  vagina  (vaginismus)  and  then  chronic  catarrh,  hyper- 
trophy of  the  cervix  with  erosions,  fistulas,  and  anomalies  of  development. 


1S4  CEXEKAL   l>.\  ril(»L()(;\'   AM)  TllKliArV   Ul''  J^^SANITV. 

It  is  only  very  seldom  that  malignant  and  other  new  growths  lead  to 
mental  disturbance,  at  most  only  indirectly  to  n>olancholia  of  psychic  origin, 
or  in  the  slate  of  marasmus  to  delirium  of  inanition. 

Insanity  due  to  uterine  disease  has  no  feature  that  particularly  dis- 
tinguishes it.  The  notion  that  it  must  invariably  be  accompanied  by  erotic 
or  hysteric  symptoms  is  erroneous.  This  fad  is  to  be  explained  l)y  tlic  vary- 
ing nature  of  the  pathogenesis. 

Sexual  disease,  in  tliat  it  may  cause  profuse  menses,  leuciuilica,  etc., 
induces  in  a  great  number  of  cases  only  a  general  weakening  of  tlie  constitu- 
tion, which  then  constitutes  a  predisposition  to  neuroses  and  psychoses.  In 
other  cases  such  a  predisposition  precedes  the  genital  a  (lection,  and  the  latter 
intensifies  the  former,  or  constitutes,  under  such  circumstances,  the  accessory 
cause  of  the  disease. 

Its  influence  may  be  effectiial: — 

(a)  Psychically,  in  that  it  induces  sterility,  with  its  depressing  conse- 
quences. 

(h)  Directly,  through  the  nervous  system,  either  by  irradiation  or  reflex 
influence  of  uterine  irritation  directly  afl'ecting  the  psychic  organ,  or  indirectly 
through  vasomotor  influence;  or  finally  through  causing  neurasthenia 
sexualis.  In  the  first  instance  it  usually  takes  the  form  of  paranoia  with 
erotic,  expansive,  or  persecutory  primordial  delusions;  sometimes  n_ympho- 
mania.  Too,  the  cases  of  insanity  due  to  vaginismus  and  those  occurring  after 
defloration,  have  a  similar  origin  (demonomania,  erotic  hallucinatory  insanitj'^ 
- — Schule).  In  cases  that  have  the  second  manner  of  origin  the  pictures  are 
usually  those  of  acute  melancholia  or  mania,  with  profound  disturbances  of 
consciousness,  and  with  erotic  or  equivalent  religious  or  demonomaniac 
deliria. 

The  psychoses  arising  on  a  neurasthenic  basis  take  the  form  of  paranoia 
with  delusions  of  physical  persecution,  dysphrenia  neuralgica,  or  chronic  mel- 
ancholic foJie  raisoiiitaiite.  A  neuropathic  constitution  as  a  necessary  condi- 
tion, where  the  origin  is  neurotic  in  nature,  seems  to  me  to  be  more  than 
probable. 

(cj  Humoral,  by  inducing  anemia.  In  these  cases  insanity  takes  the 
form  of  melancholia  almost  without  exception,  and,  as  Schule  emphasizes,  not 
infrequently  with  delusions  of  sin  and  demonomania. 

In  connection  with  sexual  diseases  it  is  necessary  here  to  refer  to 
menstruation  and  its  anomalies  as  causes  of  insanity. 

Here  Ave  are  also  able  to  recognize  a  mental,  a  humoral,  and  a  neurotic 
manner  of  origin.  The  failure  of  the  menstrual  process  may  act  psychically 
in  that  it  induces  a  fear  of  incurable  disease  or  pregnancy  (Mayer). 

A  humoral  manner  of  origin  is  present  where  profuse  menses  lead  to 
anemia,  and  thus  dispose  the  individual  to  disease,  intensify  a  predisposition 
that  is  already  present,  or  act  as  an  accessory  cause. 

The  cases  of  neurotic  origin  are  most  important.  In  order  to  understand 
them  it  is  necessary  to  remember  the  fact  that  physiologically  the  menstrual 
process  throws  the  central  nervous  system  into  a  state  of  intensified  excita- 
bility and  lessened  resistive  power  to  irritation.  If  an  individual  be  neuro- 
pathic, tainted,  and  bordering  upon  instability,  then  the  normal  process  of 
menstruation  may  be  sufficient  in  itself  to  induce  disturbance  of  tlie  central 
nervous  organs,  which,  depending  upon  the  severity  of  the  taint,  expresses 


TKIO  C/M'SKS  ()(.'  IN'SANITV.  '  185 

itself  in  all  degrees,  from  sliglit  migraine  to  the  severest  forms  of  psycho- 
pathic disturbance.  There  are  cases  in  which,  with  the  regular  rcKiiircnce  of 
the  menstrual  period,  mental  disturbance  oecui'S,  and  then  an  atrtual  periodic 
insanity  results  {vide  "Special  Pathology").  That  it  is  not  the  loss  of 
menstrual  blood,  but  a  complicated  nervous  process  in  the  ovarian  nerves 
induced  by  ovulation  that  is  determinant  is  shown  by  certain  cases  in  wliicli 
the  paroxysms  at  the  time  of  the  menstrual  period  occur  in  the  absence  of  any 
menstrual  flow.  The  neurotic  intermediate  link  is  probably  to  be  found  in 
vasomotor  disturbances  of  the  brain  reflected  from  the  ovarian  nerves. 

In  some  few  cases  insanity,  chiefly  acute  mania,  has  been  observed  to 
follow  upon  a  sudden  suppression  of  the  menstrual  flow  by  fright,  or  taking 
cold;  or  the  suppression  of  menses  was  regarded  as  the  cause  of  insanity.  In 
such  cases  it  might  also  be  assumed  that  a  collateral,  vicarious  fluxion  to  the 
brain  constituted  the  intermediate  link.  As  a  rule,  however,  insanity  and  sup- 
pression of  the  menses  are  co-eff'eets  of  the  same  cause,  and  have  a  vasomotor 
origin.  Too,  chronic  amenorrhea,  so  often  regarded  as  a  cause,  is  at  least 
somatically  not  so,  but  it  is  rather  an  accompanying  symptom  of  insanity,  and 
the  common  cause  of  both  conditions  is  defect  of  development,  disease  of  the 
genitals,  or  some  disturbance  of  general  nutrition. 

Diseases  of  the  Male  Sexual  Okgans.— They  play  rather  an  unim- 
portant etiologic  role,  and,  as  a  rule,  they  are^  symptoms  of  a  neuropathic 
state,  congenital,  or  acquired  as  a  result  of  sexual  excesses,  especially  onanism. 

This  is  true  of  spermatorrhea  and  impotence.  In  such  cases  of  actual 
mental  disturbance  (melancholia,  hypochondriac  melancholia)  there  is  prob- 
ably a  marked  congenital  or  acquired  disposition. 

Inability  to  perform  coitus  on  the  part  of  individuals  sexually  weak  who 
suspect  their  sexual  power  as  a  result  of  failure  in  their  first  attempt  at 
coitus,  and  which,  owing  to  the  shame  of  the  first  failure,  acts  as  an  inhibitory 
imperative  idea  to  prevent  success  in  subsequent  attempts,  is  in  itself  a 
pathologic  phenomenon. 

Here  should  be  mentioned  the  hypochondriac  melancholia  with  delusions 
of  being  syphilitic  that  sometimes  occurs  in  neuropathic  men  Aveakened  by 
sexual  excesses,  as  a  result  of  innocent  excoriations,  balanitis,  gonorrhea,  etc. 

Sexual  Excesses. 

The  significance  of  abuse  of  the  sexual  organs  in  the  origin  of 
neuropsychoses  and  psychoses  is  by  no  means  small,  and  when  the 
important'  relations  in  which  the  sexual  nervous  system  stands  to 
the  nervous  system  in  general,  including  those  portions  of  it  upon 
which  the  activity  of  the  mind  depends,  are  considered,  this  is  at  once 
comprehended.  Disturbances  of  the  sexual  functions,  like  those  of 
digestion,  exert  a  powerful  influence  upon  the  emotional  state,  which 
in  these  cases  is  usually  depressed  or  markedly  hypochondriac. 

Sexual  excesses  may  create  a  predisposition  to  mental  diseases, 
intensify  a  predisposition  already  present,  or  act  as  an  accessory  cause. 
The  intermediate  factor  in  the  pathogenesis  of  nervous  and  mental 
diseases  is  neurasthenia  induced  by  abusus  veneris. 


ISO  GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  conditions  are  most  unfavorable  wlien  this  aeqnired  pro- 
disposition  is  added  to  one  that  is  original.  Xuniorons  tainted 
individuals,  however,  are  found  in  this  condition,  in  so  far  as,  with 
them,  th<3  sexual  impulse  arises  abnormally  early  and  with  abnormal 
intensity,  and'  very  fre(|uently,  besides,  finds  some  perverse  manner 
of  satisfaction.  In  such  cases  sexual  excess  is  not  so  much  a  cause  as 
a  symptom,  or  at  least  a  result  of  an  abnormal  condition,  just  as 
in  those  cases  where  an  existing  menial  disease  (mania,  dementia 
paralytica,  senile  dementia)  leads  to  sexual  abuse. 

This  clinical  fact  must  be  taken  into  consideration  in  determining 
the  etiology  of  a  given  case.  Cases  of  insanity  due  to  sexual  abuse 
develop  out  of  a  neurasthenic  condition,  and  manifest  neurasthenic 
symptoms. 

Mental  disease  due  to  sexiial  excess  arises  more  readily  when  the 
person  is  very  young  or  well  advanced  toward  old  age.  Moreover,  the 
degree  of  any  taint  is  of  decisive  significance.  At  the  same  time, 
much  depends  upon  the  manner  of  excessive  sexual  indulgence. 

(a)  Excesses  in  natural  sexual  indulgence  have  a  much  less  fatal 
effect  than  when  the)'^  are  unnatural.  Their  influence  is  directly  ex- 
hausting, predominatingly  cerebral.  ^Vomen  endure  sexual  abuse 
better  than  men,  probably  because,  with  them,  the  nervous  system  is 
less  intensely  excited  in  the  sexual  act. 

Severe  cerebrasthenia,  senium  praecox,  dementia  paralytica,  and 
severe  melancholia  with  hypochondriac  coloring  may  develop  as  a 
resiilt  of  the  exhausting  influence  of  excessive  coitus.  As  a  rule,  how- 
ever, there  are  other  accessory  causes  operative  at  the  same  time. 
Coitus  inte-rruptus  and  reservahis  are  not  without  danger  to  women. 
They  lead  at  least  to  sexual  neurasthenia,  with  all  its  possiljle  dangers 
for  mental  integrity. 

(i)  ]\ruch  more  injurious  and  of  greater  ethic  significance  are 
the  unnatural  sexual  excesses  mainly  committed  in  the  form  of 
onanism.  The  reason  for  this  lies  probably  in  the  fact  that  this  habit 
is  often  associated  with  a  neuropathic  constitution,  is  practiced  exces- 
sively often  at  a  very  esiT]y  age,  and  constitutes  an  inadequate,  un- 
physiologic  excitation  of  the  nervous  system.  This  is  especially  "true 
of  so-called  psychic  onanism,  in  which  ejaculation  is  induced  solely  by 
means  of  exciting  the  imagination    (ideas  of  lascivious  situations). 

The  effect  of  onanism  is  the  induction  of  a  genital  neurosis  (pol- 
lutions) which  extends  to  the  lumbar  cord  and  leads  to  general 
neurasthenia. 

On  the  basis  of  this  predisposition  psychoses  develop  later  as  a 
result  of  various  accessory  causes.     According  to  my -experience  thus 


Till-]  f'Al^'^KS  OF  INSANITY.  187 

far,  which  is  by  no  means  small,  tliore  is,  besides,  almost  always  an   / 
original  neuropathic  constitution;    and,  in_ cases  w]i or;;  this  does  not 
exist,  onanistic  excesses  scarcely  lead  to  the  development  of  conditions 
beyond  the  limits  of  an  asthenic  neuropsychosis. 

That  this  vice  occurs  in  the  female  sex  and  exertf;  an  injurious 
influence  is  the  general  experience  of  gynecologists,  neurologists,  and 
alienists.  The  disease-pictures  which  present  themselves  under  such 
circumstances  do  not  seem  difl'crent  from  those  that  occui-  in  men. 

On  the  basis  of  irritable  weakness  of  the  central  nervous  system  (neu- 
rasthenia) due  to  onanism,  the  pathogenesis  of  the  onanistic  psychoses  is 
varied. 

la)  It  may  be  psychic  as  a  result  of  intermediate  psj'chic  causes.     These    i 
are  spontaneous  feelings  of  remorse,  shame,  and  fear  of  the  results  of  the  vice,    i 
in  conne^ctTön  Avith  the  painful  consciousness  of  being  unable  to  overcome  the     ' 
RaHiLby  force  of  will ;  or- THTestTfeelings  may  arise  from  the  reading  of  certain 
popular   bonks   which  xeLpxesent_the._c.ongeguences   of   self -abuse   in  an   exag- 
gerated way.     Besides,  in  those  contemplating  marriage,  the  actual  relatively 
organic^r  psychic  impotence  may  be  the  psychic  cause. 

In  such  cases  w^e  observe  metajic]iolia:::vvüIi- intense-.(h;!:pocbondr iac )  noso- 
phobicUßätures  expressed  in  a  fear  of  \tabes,  consumption,  or  insanity,  in  ac- 
cordance with  the  predominating  symptoniax)f  neurasthenia. 

(bj  Tlie  intermediate  factor  may  be  somatic,  as  a  result  of  the  effect  of/ 
weakeiiing  influences  such  as  insufficient  nourishment,  mental  or  physical  over- 
exertion,  etc.     The   form   of   the   disease-picture   in   such   cases   seems   to   be 
essentially  conditioned  by  the  defective  constitutional  element. 

If  the  latter  is  mild  in  degree,  stuporous  or  acute  hallucinatory  insanity  | 
arises  as  a  pure  exhaustion  psychoiTeiiröstgr'f'üpoir'ä  degenerate  foundation 
(pe'rhaps~älso  without  such  when  excessive  onanism  has  been  practiced  from  a 
very  early  age)  states  of  primary  progressive  dementia  develop.  At  the  be-  r 
ginning  and  episodically  there  may  be  hallucinatory  delirious  states:  raptusj 
primordia!  deliria,  catatonic  symptoms,  and  states  of  maniacal  excitement 
with  impulsive  acts".""  EHTtylh  This  condition  of  degenerate  moral  imbecility 
the«ris^läTähifestBTi"i0SB-Trf-?t1uc"lind~esthetic  feejing  (uncleanliness.  impulses 
for-disgU3ting^-thTTrgy)-rTrb'50lTiIe~!ack  of  emotion  and  will,  with  termination  in 
the  deepest~dem'entia. 

'        Certain  states  of  paranoia  and  insanity  with  imperative  ideas  are  to  be 
mentioned  as  other  decidedly  degenerate  disease-pictures. 

Symptoms  that  belong  more  or  less  to  all  sexual  psychoses  clinically  are 
those  of  neurasthenia;    and  hallucinations  of  smellj3f_an  unpleasant  character  ~\ 
(feces,  odor  of  corp:ses_,__et(^^^re^eldqm_wanting.-_Ji      infrequently  in -tliese     I 
eäses_th£re_ar.e--iuUo^3ile pto id  and  .ciat.a.tonic^syjnpl_ojii.s. 

^^\^nt  of  Sexual  Satisfaction. 

This  is  frequently  regarded  as  a  cause  of  neuroses  and  psychoses, 
but  certainly  it  is  never  effectual  except  upon  the  basis  of  a  neuro- 
pathic taint  and  an  abnormally  intense  sexual  impulse.     Both  of 


ISS  CPINKKAI-   l'Al'lKH.tiCV   AND    TllKKAl'V   UF  INSAMTV. 

these  conditions  are  frequently  found  united  in  tainted  individuals. 
A  man  is  in  more  danger  than  a  woman,  since  naturally  in  him  the 
sexual  impulse  is  more  intense.  When  in  the  case  of  a  M'oman  sexual 
abstinence  is  given  as  a  cause,  we  should  carefully  ascertain  whether 
it  is  not  rather  the  lack  of  fullillment  of  her  destiny  as  wife  and 
mother,  and  thus  of  her  ethic  and  social  neetls. 

When  sexual  excitement  is  not  overcome  by  temporary  satisfac- 
tion, it  results  in  hyperexcitation  of  the  genital  sphere  (erections, 
hyperemia)  and  the  whole  nervous  system. 

Under  such  circumstances  abstinence  may  induce  such  intense 
excitement  as  to  lead  to  satyriasis,  nymphomania,  or  at  least  hallu- 
cinatory delirium.^ 

In  other  respects  the  results  of  abstinence  in  individuals  that  are 
tainted  are  essentially  the  same  as  tbose  following  onanism. 

A  general  neurasthenia  is  developed,  and  upon  this  foundation 
states  of  hypochondria,  melancholia,  paranoia^  and  insanity  of  impera- 
tive ideas  develop. 

Pregnancy ,  Confinement,  Puerperal  State,  and  Lactation. 

Directly  suggested  by  the  weakening  influences  of  sexual  ex- 
cesses, especially  in  men,  are  the  exhausting  effects  of  pregnancy 
and  the  puerperal  state  in  women.  At  any  rate,  they  have  an  equiva- 
lent significance  with  those  indulgences  which  are  so  dangerous  to 
men,  for,  among  every  100  insane  women  admitted  to  asylums,  these 
conditions  as  predisposing  and  accessory  causes  are  operative  in  17.8 
per  cent. 

Here,  as  in  all  cases  where  physiologic  phases  are  of  etiologic 
influence  in  the  production  of  mental  disease,  predisposition  is  of  great 
importance. 

Fürstner  found  hereditary  predisposition  in  61.7  per  cent,  of  his 
cases  of  this  nature,  but  Eipping  found  only  44.3  per  cent.  This 
investigator,  on  the  other  hand,  found  that  an  acquired  disposition 
was  an  important  factor,  especially  tbe  weakening  antihyo-ienic 
influence  of  factory  life,  to  which  the  majority  of  his  patients  were 
subject. 

Other  important  predisposing  factors  besides  hereditary  predis- 
position are  chlorosis,  anemia,  frequent  and  difficult  births,  long- 
continued  lactation,  severe  diseases,  profuse  menses,  and  anything  that 
weakens  the  constitution.     Puerperal  insanity  is  most  frequent   (9.3 


^Compare  thp  case  related  by  Marc-Ideler,  ii,  page  137.     Zola  seems,  in 
"Abbf'  ^louret,"  to  have  had  this  case  in  mind. 


THE  CAUSES  OF  INSANITY.  ],S0 

per  cent,  of  all  admitted),  next  conies  tJiat  of  tlic  jjei'iod  of  lactation 
(5.6  per  cent.),  and  finally  the  insanity  of  pregnancy  (3.1  per  cent.). 

(a)  The  insanity  of  pregnancy  occurs  usually  in  the  last  three 
months  of  gravidity.  Eipping  lays  great  etiologic  stress  on  the 
changes  in  the  circnlation  of  tlie  brain  (anoniia)  due  to  the  growth  of 
the  uterus,  the  addition  of  tlie  placental  circulatioi),  as  well  as  on 
cliemic  changes  in  tlio  hlood  consequent  upon  gravidity. 

The  predominance  of  insanity  as  an  accompaniment  of  pregnancy 
in  the  unmarried  is  explained  by  the  unfavorable  conditions  of  life  that 
usually  affect  such  persons,  as  well  as  l)y  the  anxiety  about  the  future 
that  naturally  arises  in  such  cases.  The  form  of  disease  which  the 
insanity  of  pregnancy  takes  is  usually  that  of  melancholia,  seldom 
mania. ^  The  rare  cases  of  insanity  that  develop  during  the  early 
months  of  pregnancy  are  really  of  short  duration  and  favorable 
prognosis.  The  insanity  of  the  later  months  does  not  end  with 
parturition,  and  sometimes  passes  on  into  mania.  The  average  dura- 
tion of  the  disturbance  is  nine  months.  Relapses  are  frecjuent  in 
subsequent  pregnancies. 

(h)  Mental  distur'bances  that  occur  during  lahor  are  transitory. 
They  are  accompanied  by  great  disturbance  of  consciousness.  Most 
frequently  in  such  cases  states  of  pathologic  affect  are  observed,  espe- 
cially in  the  case  of  unmarried  patients,  due  to  the  helpless  position, 
shame  at  the  loss  of  honor,  fright  at  the  signs  of  approaching  labor, 
and  anxiety  about  the  future.  Besides,  there  are  states  of  furious 
excitement  induced  by  labor-pains,  ■  with  delirium  and  consequent  ex- 
haustion, as  well  as  cases  of  transitory  mania,  hysteric  and  epileptic 
delirium,  and  eclampsia  with  delirium. 

(c)  Puerperal  Insanity. — Its  pathogenesis  is  dark.  Etiology  in- 
dicates predisposing  causes  which  depend,  in  joart,  upon  hereditary 
and  neuropathic  constitution ;  in  part,  on  chlorosis,  anemia,  anomalies 
of  the  uterus,  the  weakening  influence  of  preceding  severe  physical 
disease,  loss  of  blood,  protracted  lactation,  frequent  births;  in  part, 
on  the  depressing  influence  of  fear  of  death;  in  the  case  of  the 
unmarried  patients,  also  on  shame  and  anxiety  about  the  future. 

Emotional  states,  mastitis,  and  other  febrile  somatic  diseases  may 
bo  called  accessory  causes.  The  cessation  of  the  lochia  and  the  flow 
of  milk,  which  the  laity  blame  so  often,  are  symptoms,  not  causes,  of 
the  disease. 


^Schmidt  found  31.3  per  cent,  mania,  52.9  per  cent,  melancholia.  10  per 
cent,  paranoia,  5.8  per  cent,  dementia  paralytica.  Among  5  cases  of  the 
author's,  4  were  melancholia,  1  dementia  paralytica. 


100  TtEXERAL  PATlIDLOriV  AM)  THERAPY  OF  IXSAXTTY. 

In  the  cases  of  insanity  that  (,)Lrur  during  the  earlier  weeks  the 
causes  are  niainl}'  loss  of  blood,  bad  nutrition  and  diet,  emotions,  the 
beginning  of  lactation,  mastitis,  and  inflammation  of  the  uterus  and 
its  appendages;  in  those  cases  beginning  from  the  fourth  to  the  sixth 
week,  the  causes  are  disturbances  brought  about  by  the  recurrence  of 
the  menses,  especially  menorrhagia. 

The  investigations  of  l?i])i)iiig  and  Sclimidt  sliow  tlie  great  influ- 
ence of  disturbances  of  nuti'itiou  (loss  ol'  wciglit)  during  tbe  jiuerjieral 
state,  for,  from  the  time  of  admission  to  the  discharge  of  certain 
patients,  they  showed  a  gain  of  2J)  kilograms  in  weight,  and  the  insanity 
had  gradually  disappeared  with  the  increase  in  weight. 

Most  frequently  puerperal  insanity  begins  at  any  time  from  the 
fifth  to  the  tenth  day  of  the  puerperal  state.  It  assumes  no  specific 
form.  We  are  not  justified  in  calling  it  puer})eral  mania;  neverthe- 
less, nurnia  is  the  most  frequent  form  in  which  puer[)eral  insanity  runs 
its  course.^ 

During  the  first  two  weeks  of  the  puerperal  state  we  meet  cases 
of  transitory  mania,  puerperal  fever  with  delirium,  jiuerperal  fever 
with  tlie  delirium  of  inanition,  and  puerperal  psychoses  (for  the  most 
part,  mania  or  confusional  insanity,  less  frequently  melancholia,  and 
sometimes  also  primary  curable  dementia).  The  proportion  of  mania 
to  melancholia  in  these  cases  is  about  3  to  1. 

The  mental  disturbances  that  occur  in  the  later  weeks  of  the 
puerperal  state  are  manias  or  melancholias. 

Puerperal  Mania. — The  prodromal  symptoms  are  sometimes  those  of 
melancholic  depression,  which,  however,  is  but  slightly  marked  and  limited  to 
emotional  depression  and  a  tendency  to  weep.  In  the  majority  of  cases  the 
symptoms  are  those  of  maniacal  exaltation  (restlessness,  activity,  constant 
activity  of  thought,  talkativeness,  sleeplessness). 

The  brevity  of  the  prodromal  stage,  as  well  as  the  mildness  of  the 
s^miptoms  in  comparison  with  analogous  cases  of  non-puerperal  insanity,  is 
remarkable. 

After  this  prodromal  stage  has  lasted  a  day  or  more,  the  acme  of  intense 
mania  is  quickly  reached,  Avith  a  continuous  remitting  course. 

Errors  of  the  senses  play  a  great  part  in  the  deliriom  of  puerperal 
mania.  As  a  rule,  they  are  the  first  in  the  series  of  symptoms,  and  roiiiain  so 
prominently  in  the  foregroimd  that  we  may  justly  speak  of  such  cases  as 
hallucinatory  insanity  (Fürstner). 

The  duration  of  the  disease  is  from  six  to  eight  months  (according  to 
Schmidt,  even  10.3  months),  but  there  are  abortive  cases.     The  prognosis  is 


'  Schmidt  found  48.7  per  cent,  mania,  38.9  per  cent,  mehmeholia,  5.5  per 
cent,  paranoia,  1.4  per  cent,  circular  insanity.  Of  the  author's  cases,  17  were 
mania,  4  melancholia,  10  hallucinatory  insanity,  1  paranoia,  6  acute  dementia. 


THE  CAUSES  OF  INSANITY.  191 

quite  favorable  If  the  disease  ends  in  recovery,  in.  the  ma jorily  of  eases  the 
I)atient  passes  through  a  stage  of  stupor  which  seems  to  be  wanting  only  in 
mild  cases  (abortive).  Memory  for  the  events  of  this  stage  of  sevei'e  mental 
exhaustion  is  very  incomplete.  Out  of  this  stage  the  piilient  comes  to  herself 
either  suddenly  or  gradually. 

Puerperal  mania  has  no  specific  symptom.  That  there  is  a  predominating 
erotic  coloring  of  the  delirium  is  incorrect.  Distinguisliing  it  from  non- 
jmcrperal  mania  are  tlie  shortness  uf  (he  i)r(i(lr()mal  stage  ami  the  mildness  of 
the  symptoms,  in  this  [leiiod,  so  that  tlie  disease,  as  it  were,  breaks  out 
primarily  and  quickly  reaches  its  acme;  also  tlie  primary  occurrence  of  erroi's 
of  the  senses  aiul  prcpon(h'rance  of  them  in  the  disease-picture  (P'ürstner). 
In  general,  these  i-iscs  present  severe  forms  of  mania  with  great  disturbance  of 
consciousness.  The  postmaniaeal  stuporous  stage  of  exhaustion,  which  Fürst- 
ner insists  upon  as  diagnostic,  and  which  is  almost  never  wanting,  is  explained 
by  the  long  duration  antl  intensity  of  the  disease. 

Puerperal  melancholia,  which  is  less  frequent,  is  of  less  favorable  prog- 
nosis, and  it  lasts  longer  than  mania  before  recovery;  on  an  average,  about 
nine  months.  Deep  disturbance  of  consciousness  and  the  demented  coloring 
of  the  disease-picture  in  such  cases  are  also  dependent  upon  exhaustion,  and  are' 
notewortliy.  Schmidt  emphasizes  the  morose,  distracted,  dreamy,  forgetful, 
and  senseless  condition  of  such  patients,  as  well  as  the  frequent  hallucinations 
and  intercurrent  attacks  of  anxiety. 

Puerperal  insanity  may  also  occur  after  abortion  when  there  has  been 
great  loss  of  blood.  It  is  distinguished,  like  all  insanities  induced  by  acute 
nutritive  disturbances  of  the  brain,  by  multitudinous  errors  of  the  senses, 
especially  those  of  sight.  In  these  cases,  too,  convulsions  are  not  infrequent. 
The  prognosis  is  favorable.  The  average  duration  is  placed  by  Pvipping  at  five 
months. 

(d)  Insanity  of  Lactation. — The  insanit}^  of  nursing  women  is 
probably  always  to  be  referred  to  anemia.  Difficult  confinement  and 
the  general  and  local  diseases  of  the  puerperal  state  have  a  predispos- 
ing influence.  Nursing  too  long  and  too  frequently  in  proportion  to 
the  general  strength  acts  as  the  exciting  cause.  Insanity  seldom  occurs 
before  the  third  month.  The  predominating  form  of  disease  is  mania, 
less  frequently  melancholia.^ 

The  prognosis  is  not  unfavoraljle,  but  it  is  less  favorable  than  that 
of  puerperal  insanity.  The  average  duration  of  the  disease  is  about 
eight  months  in  asylum  practice. 

The  practical  importance  of  this  etiologic  group  of  insanities  justifies 
some  reference  here  to  treatment.  First  of  all,  on  the  admission  of  the  patient 
a  careful  physical  examination  should  be  made,  and  the  thermometer  should 
be  used  in  order  to  be  sure  that  no  puerperal  process  or  fever  is  overlooked. 


^  Schmidt  found  42  per  cent,  mania,  40  per  cent,  melancholia,  6.7  per  cent, 
acute  dementia,  3.4  per  cent,  dementia  paralytica.  The  author  found,  in  29 
cases,  mania  19  times,  melancholia  6  times,  delusional  insanity  3  times,  and 
delirium  acutum  once. 


193  GENERAL  PATHOLOGY  AXD  THJCnArV  OF  TXSAXTTY. 

The  evident  anemic  basis  of  insanity  occurring  under  such  circumstances 
demands  imperatively  rest  in  bed  and  good  nourishment.  Refusal  of  food 
must  not  be  indulged  too  long;  in  such  a  case  clysters  of  prepared  foods 
should  be  resorted  to  early.  The  medical  indications  are  tonics,  especially 
iron  in  tlie  form  of  the  peptonized  albuminate  and  dialyzed,  extracti  secali 
cornutum,  nux  .vomica,  quinine  in  .Mahiga  wine,  with  Avine  and  beer.  iSleep- 
lessness  can  hardly  ever  be  overcome  by  morpliine;  the  extract  of  opiiun  with 
quinine  acts  better.  Alcoholics,  especially  beer,  have  the  best  effect.  Occa- 
sionally chloral  hydrate  or  paraldoiiyde,  wet  packing,  and  subcutaneous  injec- 
tions of  camphoi-  wlicre  there  is  not  too  marked  a  degiee  of  anemia  with 
fluxidn  to  the  brain, — i.e.,  with  e.xcited  action  of  the  heart, — and  lukiwann 
baths  nuiy  be  tried.  Care  should  be  taken  to  watcli  tlie  condition  of  the 
genital  organs  in  their  jirocess  of  retrograde  cliange.  At  their  reciu-rence  the 
menses  are  profuse  and  liave  a  weakening  effect,  causing  a  relapse.  In  such 
cases  it  is  necessary  to  prevent  the  loss  of  umieecssary  blood  by  the  usual  em- 
ployment of  ergot  and  hydrastis. 

InsanHy  Due  io  Iiiin.rii-itl'ton. 
A I  roll  ol. 

Of  the  substances  falling  under  this  head  tltat  exert  a  deletcrions 
influence  upon  the  central  nervous  system,  alcohol  plays  the  most 
important  role,  owing  to  common  overindulgence  in  it. 

Indulgence  in  spirits  has  become  a  veritable  curse  to  entire  nations,  for 
it  not  only  impoverishes  the  individual  and  the  race,  but  it  seriously  inter- 
feres with  the  moral,  intellectual,  and  physical  welfare  of  its  victims. 

Tlie  inclination  to  indulgence  in  alcohol  is  increa.sed  by  habit,  ami  in- 
heritance tends  to  continue  an  indulgence  that  has  become  liabitual,  partly 
directly,  and  partly  indirectly,  since  the  abuse  of  alcohol  by  descendants  whose 
constitution  has  become  weakened  leads  to  instinctive  use  of  the  intoxicant 
(Bär).  Tlie  impulse  to  indulge  in  alcohol,  thus  implanted,  often  remains 
latent  until,  as  a  result  of  some  severe  acute  or  chronic  disease,  emotional 
disturbance,  or  the  like,  the  asthenic  nervous  system  has  become  weakened.' 

Besides  the  innumerable  accidents,  crimes,  suicides,  and  grave  nervous 
diseases  that  arise  either  directly  or  by  way  of  inheritance,  over-indulgence  in 
alcohol  is  one  of  the  most  important  causes  of  insanity  (chronic  alcoholism 
and  the  psychoses  aeveloped  upon  this  foundation;  epilepsy  and  dementia 
paralytica) . 

The  number  of  cases  of  insanity  due  to  drink  varies  between  one-ninth 
and  one-tliird  of  the  admissions  to  asylums,  in  accordance  with  class,  nation- 
ality, climate,  etc.  In  these  figures  we  do  not  reckon  the  physically  and  morally 
degenerate- — habitual  drunkards  who  wander  about  in  society  with-  detriment 
to  the  family,  public  morality,  and  safety. 


*In  a  similar  manner  predisposed  individuals  come  to  indulge  in  mor- 
phine, chloral,  and  opium.  It  is  remarkable  how  frequently,  and  in  spite  of 
the  neurasthenic  condition,  unusually  large  doses  of  such  drugs  are  borne. 


THE  CAUSES  OF  INSANITY.  103 

The  ways  in  Avliicli  iilcnhol  exerts  an  injurious  influence  on  the  jiervons 
system  are  varied.  (Jf  first  importance  is  the  direct,  partly  by  means  of 
chemic  irritation  wliicli  clianges  the  tissues,  and  partly  vasomotor;  for  alcohol 
exerts  a  paralyzinj^  cfTect  upon  the  brain.  Dilatation  of  the  smallest  vessels 
is  induced  and  atheromatous  degeneration  of  those  somewhat  larger,  as  a 
result  of  which  a  favorable  soil  for  the  development  of  apoplexy  is  created. 
Its  influence  to  induce  vascular  paralysis  is  recognized  in  the  enlargement  of 
vessels  (lowered  tone),  lymph-stasis,  and  emigration  of  the  white  blood- 
corpuscles,  as  a  result  of  which  acute  clouding  and  thickening  of  arachnoid 
and  pia,  as  well  as  increase  in  the  growth  of  Pacchionian  bodies,  result. 
Pachymeningitis  htemorrhagica  also  is  not  infrequent. 

The  exciting  influence  upon  the  neart  at  first  induces  fluxions,  wliicli  are 
further  increased  by  hypertrophy  of  the  cardiac  muscle. 

In  the  later  stages  the  cardiac  muscle  undergoes  fatty  degeneration,  and 
disturbances  of  circulation  are  thus  induced,  as  well  as  by  vasomotor  paresis 
and  atheromatous  degeneration. 

The  nutrition  of  the  psychic  organ  suffers  indirectly  through  changes  in 
the  composition  of  the  blood  (hydremia,  diminution  of  fibrin),  profound  dis- 
turbance of  general  nutrition,  tissue-changes  due  to  fatty  degeneration  of 
organs  (liver),  chronic  gastric  catarrh  with  fatty  degeneration  of  the  gastric 
glands,  cirrhosis  of  the  liver,  and  chronic  interstitial  parenchymatous  nephritis. 

But  the  vice  of  drunkenness  also  exercises  a  mental  effect  through  the 
social  conflicts  into  which  the  drunkard  falls  and  the  ruin  of  his  financial 
standing,  his  family  happiness,  and  his  honor  as  a  citizen. 

Finally,  it  should  be  considered  that  drinking  is  frequently  a  means  of 
overcoming  remorse,  care,  anxiety,  or  a  bad  conscience,  and  under  such  cir- 
cumstances two  powerful  etiologic  factors  work  together  to  produce  insanity. 
The  detrimental  effect  of  amyl  alcohol  as  compared  with  the  less  injurious 
influence  of  ethyl  alcohol  was  alluded  to  on  page  140.  The  Avidespread  use  of 
absinthe  in  France  and  Switzerland  exerts  an  especially  pernicious  influence. 

Not  infrequently  the  injurious  influence  of  alcoholic  excesses  is  added  to 
others  of  a  physical  nature, — hunger,  exposure,  want, — and  others  of  a  mental 
nature,^conflicts  and  dangers, — as  they  affect  individuals  reduced  to  the 
misery  and  privation  of  vagabondage.  Frequently  such  a  life,  as  Avell  as  the 
impulse  to  over-indulgence  in  alcoholic  drinks,  is  a  symptom  of  mental  disease 
(weak-mindedness  with  perverse  impulses,  moral  insanity).  The  etiologic  sig- 
nificance of  drinking  sprees  is  partly  that  of  a  predisposing  cause,  in  so  far  as 
the  central  nervous  system  is  thus  Aveakened  or  cA^en  anatomically  changed, 
and  therefore  no  longer  able  to  withstand  accessory  causes;  and  partly  that 
of  an  exciting  cause,  AA^hen  alcohol  acts  on  a  brain  predisposed  in  some  Avay. 

This  predisposition  may  be  due  to  hereditary  taint,  functional  AA-eakness 
as  a  result  of  excesses,  exhausting  diseases,  head  injuries,  and  painful  or  angi-y 
excitement  (indulgence  in  drink  in  order  to  OA^ercome  care).  Under  such  cir- 
cumstances even  a  single  indulgence  may  induce  a  psychosis.  HoweA'er,  in  the 
majority  of  these  predisposing  conditions  there  is  a  lessened  poAver  of  resist- 
ance to  the  vasoparalytic  and  direct  toxic  effects  of  alcohol. 

Where  alcoholic  excesses  are  associated  Avith  a  psychosis  already  existing 
(melancholia,  mania,  dementia  paralytica)  they  increase  the  intensity  of  the 
latter,  so  that  melancholic  depression  becomes  actiA^e  melancholia  or  raptus, 
and  maniacal  exaltation  reaches  the  intensity  of  mania. 


194    GENERAL  PATHOLOOY  AXD  THERArY  OF  TXSAXTTY. 

The  psychoses  in  which  the  abuse  of  alcohol  plays  an  etiologic 
role  present,  as  might  be  expected  from  the  variations  of  the  patho- 
genesis and  the  influence  of  the  causal  factor,  various  clinical  features ; 
still  it  must  not  be  overlooked  that,  when  the  abuse  of  alcohol  is  the 
only  or  predominating  cause  of  disease,  the  disease-picture  lias  a  spe- 
cific clinical  character,  and  one  is  justified  in  such  instances  in  speak- 
ing of  alcoholic  psychoses.  The  description  of  these  belongs  to  special 
pathology,  and  will  be  found  in  the  section  entitled  "Chronic  Alco- 
holism, with  its  Complications." 

In  those  cases  in  which  the  abuse  of  alcohol  acts  only  as  an  acci- 
dental cause,  and  when  it  is  not  the  only  cause,  the  psychoses  that 
result  present  no  specific  characteristics.  At  most  in  such  cases,  where, 
shortly  before  the  outbreak  or  during  the  mental  disturbance,  alcoholic 
excesses  have  been  committed,  there  are  traces  of  alcoholic  intoxication 
and  episodic  hallucinations  in  themselves  foreign  to  the  disease-picture 
which  recall  the  errors  of  the  senses  of  chronic  alcoholism  and  espe- 
cially of  delirium  tremens,  thus  giving  color  to  the  picture. 

Too,  when  alcoholic  excesses  are  the  only  or  predominating  excit- 
ing cause  in  an  individual  predisposed  by  heredity,  head  injury,  or 
other  taint,  aside  from  the  traces  of  alcoholic  intoxication  and  certain 
suspicious  visions  of  animals,  devils,  and  the  like,  there  are  no 
symptoms  which  speak  for  the  alcoholic  origin  of  the  case.  However, 
the  course  of  such  cases,  which  are  predominatingly  acute,  with 
sudden  origin  and  rapid  subsidence,  speaks  for  the  symptomatic  na- 
ture of  the  disease.  If  there  be  at  the  same  time  symptoms  of  con- 
gestion of  the  brain  in  connection  with  the  other  signs,  then  the 
predominating  influence  of  alcohol  as  a  causal  factor  becomes  at  least 

probable. 

Other  Poisons. 

Opium. — In  a  similar  way  the  abuse  of  opimn  by  the  Orientals  and  the 
Chinese  leads  to  nervous  defect  and  psychic  degeneration,  just  as  the  abuse  of 
alcohol  does  in  the  Occident. 

Cannabis  Indica,  or  haschisch,  is  also  capable  of  inducing  delirium  and 
fuental  disturbance. 

pess  frequent  land  more  accidental  mental  disturbance  sometimes  arises 
as  a  result  of  hyoscyamus,  .conium,  datura-  stramonium,  belladonna,  and 
poisonous  mushrooms. 

Mental  disturbance  has  also  been  observed  as  a  result  of  the  medical  use 
pi  atropine.  Thus,  Michea  observed  in  cases  of  epilepsy  where  he  was  using 
atropine  for  a  long  time  in  doses  as  high  as  0.01  gram,  intellectual  dullness, 
apathy,  difficulty  of  articulating  certain  words,  slight  instability,  loss  of 
manual  dexterity,  and  slight  anesthesia. 

Kowalewsky  saw  an  atropine  psychosis  (hallucinatory  insanity)  in  a 
patient  into  whose  eyes  atropine  had  been  dropped;    after  the  administration 


THE  CLAUSES  OF  INSANITY.  105 

of  a  large  dose  the  patifni  ssaw  llaslK^s  of  .siinlifflit,  n'owds  of  animals  and 
people,  and  thought  masses  of  insects  were  creeping  over  him.  The  patient 
M-^as  entirely  pre-occupied  with  his  hallucinations.  After  a  lime  the  usual 
signs  of  atropine  poisoning  were  added.  He  recovered  in  ten  days  tinder  treat- 
ment with  morphine.  My  own  experience  and  that  of  others  show  that  the 
modern  practice  of  administering  cocaine  to  overcome  the  morphine  habit,  and 
its  use  as  a  tonic,  when  continued  and  employed  in  a  dose  above  0.3  gram  a 
day,  may  induce  mental  distui'bance  (hallucinatory  delirium).  In  these  cases 
true  physical  and  mental  marasmus  is  developed.  Not  infiequently  there  is 
episodic  toxic  delirium,  which,  for  the  most  part,  is  based  upon  visual  and 
auditory  hallucinations  very  mucli  resembling  those  induced  by  alcohol  (delu- 
sions of  persecution,  jealousy,  visions  of  multitudes  of  small  animals,  etc.). 
Delirium  consequent  upon  abstinence  from  the  drug,  such  as  occurs  in  those 
addicted  to  morphine,  I  have  never  seen,  though  I  have  always  stopped  the 
cocaine  completely  at  the  beginning  of  treatment. 

Similar  experiences  are  reported  in  the  use  of  salicylic  acid.  A  man  of  2.5 
had  an  attack  of  pleurisy  and  took  9  grams  of  sodium  salicylate  daily.  In  a 
few  days  hallucinatory  delirium  occurred,  at  first  joyful,  then  frightful  in 
nature.  The  patient  saw  a  scafi'old,  heard  his  death  sentence  pronounced,  and 
felt  forms  that  lay  on  him,  leading  to  anxiety,  depression,  and  fear  of  death. 
The  hallucinations  disappeared  within  a  week  after  the  discontinuance  of  the 
drug,  though  for  several  weeks  afterward  slight  anxiety  and  apathy  continued. 

Not  infrequently  mental  disturbance  has  been  observed  in  cases  where 
wounds  have  been  treated  with  iodofoem.  These  iodoform  psychoses  are  to 
be  regarded  as  cases  of  toxic  delirium.  The  principal  symptoms  are  emotion- 
ality, confusion,  frightful  hallucinations  even  to  the  degi'ee  of  furious  delirium, 
which  last  from  a  few  days  to  a  few  weeks.  Usually  there  is  rapid  recovery 
after  the  treatment  with  iodoform  is  discontinued.  Sometimes  death  occurs 
from  paralysis  of  the  medulla.  The  smell  of  iodoform  on  the  breath  and  the 
proof  of  the  presence  of  salts  of  iodoform  in  the  urine  are  of  diagnostic 
importance. 

Mental  disturbance  due  to  ergot,  even  occurring  as  an  epidemic,  has  long 
been  known.  Of  11  cases  recently  reported  by  Siemens,  10  presented  features 
of  stupor,  the  picture  of  toxic  acute  hallucinatory  confusion  (stormy  course, 
multitudes  of  pleasant  and  frightful  hallucinations  of  sight).  The  stuporous 
cases  were  characterized  by  great  dullness  of  the  sensorium  and  general  weak- 
ening of  all  the  mental  functions,  in  connection  with  epileptiform  convulsions. 
At  the  same  time  there  were  cachexia,  absence  of  menses,  and  often  also  ataxia 
of  the  extremities  and  stumbling  speech.  As  prodromes  of  the  stupor  there 
were  frequently  sensory  disturbances,  precordial  anxiety,  and  delirious 
maniacal  excitement  with  amnesia.  Of  the  11  cases,  2  were  fatal  and  9  recov- 
ered.    Therapy  consisted  of  stimulating  diet,  strong  wines,  and  warm  baths. 

That  the  excessive  use  of  tobacco  may  induce  mental  disease,  especially 
paralysis,  just  as  it  produces  nervous  diseases  like  angina  pectoris,  neuras- 
thenia, and  amblyopia,  has  been  verified  on  many  occasions. 

Richter  found  conditions  of  pressure  in  the  head,  spinal  irritation,  ambly- 
opia, and  angina  pectoris  in  connection  with  anomalies  of  the  emotions.  The 
pathogenesis  is  sought  in  disturbance  of  central  nutrition  (anemia)  due  to 
narrowing  of  the  vessels  by  the  nicotine  (irritation  of  the  vascular  centers  in 
the  medulla  oblongata),  and  in  direct  trophic  disturbances.     The  prognosis  is 


lOC;         GENERAL  PATHOLOGY  AND  TJIERAPY  OF  TXSAXn'Y. 

favorable  when  abstinence  is  piactii-od  in  connection  witli  ilie  nse  of  iodide  of 
potassium  and  hydro-  and  electro-  tliornpcutirs. 

Of  the  vegetable  substances,  corn  is  yet  id  be  nieiitioned.  wliic  h,  w  Inn  it 
is  used  as  a  food  after  it  is  spoiled,  or  exclusively,  as  in  nortliern  Univ.  induces 
the  symptoms  of  so-called  peila<irous  insanity  (melanelioiia  willi  suiri<lal  im- 
pulses, inanitiouTdeliriuni,  stales  of  weak-mindedness). 

Mental  disturbances  have  also  been  observed  following,'  (lie  iiu[irn|M"r  use 
of  chloroform,  which  were  ])ossil>ly  due  to  its  vasomotor-paralyzinp  clVeil.  tU^- 
j>ression  of  the  action  of  the  heart,  and  lowering  of  blood-piessnrc.  In  such 
cases  delirium  has  been  oliser\ed,  but  also  se\erc  lasting  degenerate  disease- 
pictures  (periodic  mania,  moral  insanity). 

In  an  analogous  way  the  abuse  of  ciilokai.  alTccls  the  mind,  doublless 
as  a  result  of  disturbances  of  nutrition,  depression  of  tlic  heart's  action,  and 
diminution  of  the  energy  of  the  vascular  centers.  Many  individuals  show  a 
remarkable  immunity  to  the  influence  of  this  poison.  In  many  the' continued 
use  of  chloral  leads  to  moroseness,  depression,  and  mental  dullness.  It  has 
been  repeatedly  observed  that  the  withdrawal  of  the  usual  dose  of  chloral 
h^'drate  leads  to  hallucinatory  delirium  resembling  delirium  tremens. 

I  have  had  similar  experiences  with  the  abuse  of  paraldehj'de.  In  f)ne 
case,  where  35  grams  were  taken  -daily,  tremor,  loss  of  memory,  and  diminu- 
tion of  mental  vigor  Avere  noticeable.  A  second  case  presented  similar  symp- 
toms, with  a  daily  dose  for  a  year  of  40  gi'ams.  When  the  drug  was  with- 
drawn a  state  resembling  deliriinn  tremens,  lasting  five  days,  occurred.  'J'his 
was  complicated  by  a  severe  epileptic  attack. 

The  injurious  influence  of  the  abuse  of  absinthe  and  similar  ethereal  oils 
to  induce  severe  toxic  delirium,  similar  to  that  of  drunkards,  with  delusions 
of  persecution  and  maniacal  excitement,  has  been  largely  studied  by  French 
observers.  Gauthier  observed,  as  a  result  of  the  habitual  abuse  of  absinthe, 
irritability,  change  of  character/,  mental  weakness,  dehisions  with  predominat- 
ing visual  and  auditory  hallucinations  of  even  a  more  frightful  character  than 
those  occurring  in  chronic  alcoholism;  tremor,  epileptic  attacks,  especially 
after  renewed  excesses;  rapid  loss  of  sexual  power,  hyperesthesia,  rheumatic 
pains  at  night,  and  less  frequently  anesthesia. 

Metallic  Poisons. — In  workers  in  lead  and  quicksilver,  along  with 
more  or  less  marked  somatic  symptoms  referable  to  chronic  poisoning,  tliere 
is  not  infrequently  implication  of  the  mental  spheie.  Individual  disposition, 
manner  of  life,  and  weakening  influences^ — such  as  alcoholic  and  sexual  ex- 
cesses— are  important  accessory  causes. 

Lead  Psj/choses. — These  occur  in  painters  and  not  infrequently  in  momi- 
taineers,  sometimes  with  and  sometimes  without  other  symptoms  of  lead  poi- 
soning. Among  the  prodromes  Bartens  speaks  of  loss  of  flesh,  gastric 
disturbances,  earthy  color  of  the  countenance,  and  blue  line  on  the  gums, 
together  with  sensorial  disturbances  (di/ziness,  headache,  ringing  in  the  ears, 
and  poor  sleep),  mental  depression,  feeling  of  oppression,  irritability,  even  to 
the  extent  of  elementary  delusions  of  persecution  and  occasional  frightful 
hallucinations.  Epileptic  attacks,  paralysis,  twitchings,  and  tremors  may 
usher  in  the  disease. 

There  are  acute  cases  of  transitory  hallucinatory  delirium  ("transitory 
lead  mania" — Wunderlich)  which  may  arise  spontaneously  or  after  a  pro- 
dromal hallucinatory  stupor.     At  the  height   of   the  condition  there  is  wild 


THE  CAUSES  OF  INSANITY.  107 

mania,  with  symptoms  of  brain  irritation  and  sleeplessness.  The  duration  is 
usually  only  a  few  days.  In  favorable  cases  convalescence  is  established  after 
sleep  or  stupor.  In  other  cases  there  is  progression  to  clironic  confusion,  or 
death  with  epileptic  and  comatose  symptoms. 

The  chronic  lead  psychoses  are  cases  of  toxic  hallucinatory  confusiorial. 
insanity  or  disease-pictures  that  stand  in  very  close  relation  to  paralysis. 

Bartens  observed  six  cases  of  hallucinatory  insanity.  There  were  multi- 
tudinous hallucinations  (visual,  auditory,  sensory,  and  gustatory),  frightful 
deliria  of  persecution,  great  disturbance  of  consciousness  even  to  the  extent  of 
lack  of  recognition  of  friends  and  surroundings,  and  attacks  of  anxiety  with 
attempts  at  suicide.  At  the  same  time  there  Avas  rapid  sinking  of  nutrition 
and  motor  disturbances.  Only  one  case  recovered.  Tlie  pseudoparalytic  lead 
psychoses  begin  acutely  with  sensorial  disturbances,  (headache  and  mental 
dullness),  precordial  distress,  frightful  visual  hallucinations,  and  deliria  of 
persecution  and  poisoning,  so  that  the  condition  ("ivresse  du  ploml)" — Ball)  at 
first  simulates  certain  acute  pliases  of  chronic  alcoholism.  After  a  longer  or 
shorter  time  these  acute  symptoms  pass  to  dementia  with  paralytic  disturb- 
ances of  motion  and  marasmus,  which,  however,  in  cases  that  end  favorably, 
pass  away  after  a  few  months.  Of  ten  cases  reported  in  French  literature, 
cited  by  Regis,  eight  are  said  to  have  recovered. 

The  differential  diagnostic  points  from  common  paralytic  dementia  are 
the  etiology,  the  earthy  color  of  the  face,  the  blue  line  on  the  gums,  the  acute 
outbreak  of  the  toxic  symptoms,  and  the  rapid  progress  to  the  height  of  the 
disease;  the  peculiar  disturbance  of  intelligence,  which  is  not  the  grave  dis- 
turbance of  consciousness  present  in  paralysis,  but  rather  a  mental  inhibition 
than  mental  defect,  and  which  appears  as  an  effect  of  sensory  loss  rather  than 
the  result  of  a  general  loss  of  cortical  functions,  with  disappearance  of  all  the 
elements  of  consciousness  of  time  and  space. 

Mercurial  Psi/cliOfies. — As  manifestations  of  chronic  mercurial  poisoning 
on  the  part  of  the  central  nervous  system,  Maunyn  describes  states  of  great 
psychic  excitability  to  external  impressions,  remarkable  susceptibility  to 
fright,  pre-occupation,  anxiety,  sleeplessness  with  inclination  to  hallucinations 
("mercurial  irritabilit}^"),  together  with  simultaneous  symptoms  of  mercurial 
poisoning  (anemia,  gastro-intestinal  catarrh,  salivation,  tremor).  Out  of  such 
conditions  mania,  melancholia,  and  states  of  mental  weakness  may  develo]j. 

Bronilsni. — Wlien  laige  daily  doses  of  bromide  salts  (exceeding  6  grams) 
are  used  continuously,  about  the  third  week  poisoning  occurs. 

This  state  of  bromism  is  manifested  in  a  reduction  of  the  energy  of ■  the 
heart  (the  effect  of  the  potassium?)  and  the  cerebral  cortex.  The  signs  in- 
dicative of  the  beginning  of  bromism  are  muscular  weakness,  tremor,  and 
disappearance  of  the  palatal  and  pharyngeal  reflexes.  Then  stupor,  even  to 
the  degree  of  deep  dementia,  occurs  (great  disturbance  of  apperception  due  to 
inexcitability  of  the  cortical  centers).  Amnesic  aphasia,  drawling  speech,  and 
stumbling  gait;  general  paresis,  with  retention  of  cutaneous  sensibility: 
demented  expression;  difficulty  in  movement,  decrease  of  muscular  tone,  and 
pale,  cachectic  color;  marked  loss  of  weight;  irregular,  rare  pulse,  and  cardiac 
weakness,  gastric  disturbances,  fetor,  and  heavy  coating  of  the  lips  and  tongue 
complete  the  disease-picture,  which,  in  its  most  advanced  stage,  may  resemble 
conditions  met  in  paretic  dementia.  Hameau  and  Falret  have  seen  death 
caused   by    cardiac   paralysis    or   paralysis   of    the   nerve-centers.     When   the 


los  CEXERAL  PATirOLOOY  AND  TIIERAPV  (W  IXSANITV. 

bromide  is  stopped  tlicse  symptoms  disappear  in  a  week  or  two.  Generous 
diet,  alcohol,  and  injections  of  strychnine  have  a  favorable  eO'ect.  CliiUlren 
bear  bromides  better  than  adults;    men  better  than  wcnneii. 

i'oisoNOi's  Gases. — Under  this  heading  belongs  carbonic  o.xidc  gas,  the 
influence  of  which,  as  sliown  by  experiments  and  accidental  deaths,  induces 
cerebral  hy])ereniia  whicli  may  reach  the  extent  of  apoplexy  and  softening. 
Eulenburg  has  seen  transitory  mania  from  poisoning  with  carbonic  oxide  gas. 
Simon  has  observed  encephalomalacia,  which  sometimes  occurred  only  after 
some  Aveeks,  preceded  by  continual  headaches  and  dizziness. 

Moreau  states  that  he  has  seen  chronic  poisoning  oy  this  gas  in  bakers. 
cooks,  etc..  who  sometimes  through  nuinths  sulTered  with  symptoms  of  brain 
hyperemia,  (licadarlif.  prosurc  in  llic  tciiiplc^,  liiigiiig  in  (he  cars,  loss  of 
appetite,  muscular  wcakiicss),  and  in  liis  opinion  this  predisposition  formed 
the  foundation  upon  wliiili  the  slightest  causes,  especially  drink,  led  to  the 
outbreak  of  the  disease  (vague  delusions  of  persecution  with  hallucinations  of 
hearing  and  sight — phosjjhenes,  angels,  saints:  less  licipitiit  1  y  (Udusions  of 
poisoning,  with  hallucinations  of  smell).  Whether  these  aliuonual  conditions 
are  to  be  attributed  merely  to  carbonic  oxide  gas,  and  imt  ratiier  to  caloric 
influence  in  connection  with  drink,  must  remain  luideeided. 

Carbon  Disiiliiliide. — The  inhalation  of  this  gas  in  factories  where  rubber 
is  used  has  been  observed  to  induce  mental  disturbance.  In  two  cases  observed 
by  Voisin,  and  in  one  case  by  Delpeeh,  the  symptoms  were  headache,  deafness, 
dizziness,  visual  and  auditory  hallucinations,  crawling  and  pricking  sensations 
in  the  extremities,  and  melancholic  depression  followed  by  mania  with  general 
hyperesthesia  a^nd  sleeplessness. 

At'TOGKNtc  Poisoning. — For  the  sake  of  completeness  we  should  men- 
tion here  the  fact  that  the  products  of  retrograde  metabolism  and  their  reten- 
tion in  the  organism  may  give  rise  to  states  of  intoxication.  Thus,  in  the 
retention  of  urine  we  have  uremia  (sonniolence,  coma,  epileptic  attacks,  with 
postepileptic  psychic  affections)  :  also  states  of  excitement  with  coina  in 
diabetes,  which  has  been  referred  to  acetonemia;  and  psychic  depression  due 
to  choleniia  (icterus). 

Wagner,  in  recent  observations,  calls  attention  to  the  possibility  of  the 
origin  of  certain  forms  of  insanity,  such  as  the  hallucinatory,  delusional,  and 
depressed  conditions,  through  auto-intoxication  i-esulting  from  intestinal  dis- 
turbances, with  absorption  of  ferments,  ptomaines,  leucomaines,  etc.  He 
observes  that  the  acetonuria  and  large  indican  elimination  residting  from  the 
decomposition  of  albumin  in  the  bowel  can  be  relieved  by  thorough  cleansing 
of  the  intestinal  tract  and  disinfecting  it  by  means  of  calomel  and  iodoform. 
Special  mention  should  be  made  of  the  interesting  disturbances  of  phys- 
ical and  mental  development  and  functions,  occurring  as  a  result  of  abnormal 
development,  atrophy,  or  removal  of  the  thyroid  gland,  which  has  the  impor- 
tant function  to  render  harmless  the  toxic  elements  of  metabolic  processes.  In 
connection  with  the  functional  disturbances  of  the  thyroid  and  their  effect 
upon  metabolism  should  be  mentioned  myxedema,  cachexia  strumipriva,  and 
cretinism.  The  mental  symptoms  incident  to  the  first  two  conditions  are 
mental  torpor,  slowness  of  thought,  and  weakness  of  mind  and  will,  even  to 
dementia.  There  have  been  observed  periods  of  melancholia,  stupor,  and  hal- 
lucinatorv  delirium.  In  addition  there  occur  changes  in  the  skin;  subnormal 
temperature;    weak,  clumsy,  and  diflicult  movements;    and  slowness  of  speech. 


PART  THIRD. 

Course,  Duration,    Termination,  and   Prognosis 
of   Mental   Diseases. 


CHAPTER  I. 

Course  and  Duration  of  Insanity. 

Aside  from  the  symptoms^  the  most  important  phenomenon  of 
insanity  is  the  course  of  the  disease.  Insanity,  like  otlier  diseases  of 
the  brain,  presents  certain  modes  of  evolution  and  various  possibilities 
of  termination  which  have  been  determined  empirically.  In  general, 
insanity  manifests  itself  as  a  chronic  disturbance  of  the  psychic  organ, 
the  duration  of  which  is  measured  by  months  or  even  years ;  but  there 
are  exceptional  cases  of  the  psychoneuroses  of  acute  and  subacute 
course  the  duration  of  which  is  a  matter  only  of  weeks.  So-called 
transitory  insanity  presents  a  peculiar  type  of  course  and  duration. 

1.  Ci-iRONio  AND  Subacute  Insanity. 

It  may  manifest  itself  (a)  as  an  isolated  attack  or  (h)  as  a  series 
of  attacks  in  which  the  symptoms  recur  periodically. 

(a)  Chronic  and  Subacute  Insanity  in  the  Form  of  an  Isolated 

Attacl'. 

Just  as  in  all  other  somatic  diseases  of  long  duration,  we  are  able 
to  differentiate  here  prodromal  symptoms,  a  stage  of  full  development, 
and  a  terminal  stage  of  the  disease. 

The  prodromal  period  of  the  disease  is  of  the  greatest  importance 
to  the  alienist.  It  makes  it  possible  to  recognize  the  pathogenesis  of 
the  malady,  and,  where  the  danger  has  been  opportunely  discovered,  it 
may  be  possible  to  prevent  the  threatened  attack. 

As  yet,  psychiatry  has  very  little  positive  knowledge  of  the  premonitory 
symptoms  of  insanity;  and  as  long  as  the  general  medical  practitioner  is 
without  such  knowledge  this  important  stage  must  pass  unobserved,  and 
pathogenesis    and    prophylaxis    must    continue    to    be    unattained  desiderata. 

(199) 


200  GENERAL  PATTTOLOnY  AND  TllERArV  OE  INSANITY. 

Only  after  the  disease  has  actually  broken  out  are  earlier  indications  recalled, 
and  these,  based  on  vague  and  imperfect  memory,  as  they  must  be,  are  but  a 
poor  substitute  for  a  scientific  history.  Thus,  scientific  study  of  the  stage  of 
incubation  of  insanity  is,  in  tlie  main,  confined  to  the  observations  made  by 
asylum  physicians  in  cases  of  a  recurrence  of  attacks  or  where  tlie  disease  is 
manifested  periodicall}'. 

When  circumstaiK-es  favor  early  and  expert  observation  of  the 
malady,  it  is  almost  always  found  that,  contrary  to  the  notion  of  the 
public  and  physicians  at  large,  which  would  make  insanity  a  disease  of 
sudden  onset,  the  disease  is  one  reaching  back  works,  months,  or  even 
years,  and  consequent  upon  disturbance  of  the  cerebral  and  psychic 
fuuctions  in  a  naiTOwor  sense. 

Often  it  is  difficult  even  for  the  expert  to  distinguish  the  first  slight  in- 
dications of  mental  disturbance  from  certain  variations  of  feeling,  of  emo- 
tional excitement,  of  taste  and  capacity  for  work  which  lie  within  the  limits  of 
mental  health.  Besides,  there  is  the  fact  that  pronounced  and  decidedly  ab- 
normal states  of  feeling  and  reaction  may  be  but  the  temporary  and  insig- 
nificant reflex  of  constitutional  or  local  troubles:  for  example,  the  depression 
and  irritability  accompanying  catarrh  of  the  alimentary  canal;  the  mental 
torpor  and  lack  of  energy  in  states  of  anemia  and  chlorosis;  the  want  of  self- 
restraint  and  incoherence  at  the  time  of  puberty.  E^^en  though  these 
symptoms  are  equivocal,  and  under  some  circumstances  unimportant,  they 
become  significant  when  the  person  presenting  them  is  subject  to  an  heredi- 
tary taint  or  presents  the  signs  of  a  neuropathic  constitution.  In  other  cases 
the  significance  of  these  abnormal  symptoms  is  diminished  by  the  fact  that 
there  have  been  previous  disagreeable  events  of  which  the  symptoms  are  the 
physiologic  reaction.  It  is  ratlier  the  unusual  intensity  and  duration  of  the 
affective  disturbances  that  raise  the  first  suspicion  of  their  pathologic  founda- 
tion. Not  infrequently  its  recognition  is  made  the  more  difificult  by  the  cir- 
cumstance that  the  psychosis  is  not  developed  on  the  basis  of  a  normal  mental 
personality,  but  appears  rather  as  an  intensification  of  strange  inclinations, 
impulses,  and  eccentricities  that  have  been  long  noticed  (hypertrophy  of  the 
character),  and  thus  the  change  of  personality  is  only  quantitative. 

Finally,  those  not  infrequent  cases  are  to  be  remembered  in  which  a 
psychosis  develops  out  of  a  general  neurosis  with  its  elementary  psychic 
anomalies. 

Thus,  the  physician  of  tact  and  of  special  experience  is  often  able  to 
recognize  in  the  case,  where  the  inexperienced  see  nothing  more  than  chlorosis, 
the  beginning  of  melancholia;  to  interpret  correctly  inactivity  as  abnormal 
lack  of  will;  the  nervousness  of  an  hysteric  person  as  a  sign  of  approaching 
insanity;  the  eflfects  of  overstimulation  of  the  brain  as  the  precursors  of 
dementia  paralytica. 

As  a  fact  of  experience,  it  may  be  stated  that  chronic  insanity  does 
not  begin  with  disturbances  in  the  content  of  -ideas  (delusions  and 
false  sense-perception),  but  with  afPoctive  disturbances,  with  anomalous 
feelings,  and  states  of  altered  einotional  excital)ility. 


COURSE,  nURATTON,  TERMIN ATTON,  AND  PROGNOSIS.         201 

Guislain's  view  that  insanity  begins  with  a  mfiliuifliolic  stage  is 
only  true  in  a  limited  sense.  Anxiety,  irritability,  and  depression, 
which  so  frequently  precede  the  outbreak  of  insanity,  are  not  to  he 
regarded  merely  as  melancholia.  The  depression  may  bo  physiologic, 
i.e.,  due  to  a  depressing  cause  that  is  effectual;  or  pathologic,  but 
at  the  same  time  a  reactive  manifestation  dependent  upon  the  feeling 
of  threatened  mental  disease,  of  inhibition  of  thonglit,  and  conscious- 
ness of  a  lack  of  mental  capability. 

In  numerous  eases  of  mania,  in  all  cases  of  primary  hallucinatory 
insanity  and  paranoia,  and  aiso  in  various  other  forms  of  mental  degen- 
eration, no  melancholic  premonitory  stage  is  observed.  While  in 
cases  developed  upon  the  basis  of  a  taint  the  transition  to  an  actual 
pathologic  state  is  slow,  unnoticeable,  and  almost  exclusively  of  the 
nature  of  a  quantitative  change  from  the  previous  personality, — as  an 
intensification  of  former  abnormal  feelings,  tendencies  of  thought, 
and  impulses, — or  even  when  in  such  cases  the  outbreak  is  abrupt  as  a 
result  of  a  sudden  exciting  cause;  still,  in  cases  of  insanity  not 
dependent  upon  abnormal  predisposition,  or  at  most  favored  only  by 
latent  predisposition,  or  due  to  powerful  exciting  causes,  the  moment 
of  the  beginning  or  invasion  of  the  disease  may  be  determined  with 
more  or  less  exactness. 

Besides  the  change  of  the  affective  functions  already  mentioned, 
which  may  advance  to  such  a  degree  as  to  bring  about  a  complete 
change  of  the  former  character,  there  are  also  essentially  formal  dis- 
turbances of  the  intellectual  processes  (inhibition,  difficulty  of  thought, 
imperative  ideas). 

Only  later  does  the  trouble  advance  to  disturbances  in  the  content 
of  ideas,  to  new  and  strange  associations  of  ideas,  painful  or  astound- 
ing, which  not  infrequently,  even  at  the  beginning  of  the  disease, 
awake  in  the  patient  the  warning  feeling  of  threatening  insanity. 
Frequently  before  these  abnormal  feelings  and  ideas  can  be  clearly 
described  as  a  part  of  the  waking  life,  these  new  thoughts  express 
themselves  in  dreams,  where  the  ordinary  lively  mental  intercourse 
with  the  external  world  ceases  and  the  abnormal  processes  arising  in 
the  brain  itself,  as  well  as  the  changed  sensations  coming  from 
peripheral  organs,  attain  directly  the  sphere  of  unconscious  mental  life. 

At  the  same  time,  as  the  early  expression  of  disturbances  of  nutri- 
tion and  circulation  of  the  brain,  there  are  headache,  vertigo,  disturb- 
ance of  sleep,  mental  fatigue  and  apathy,  emotional  irritability  or 
indifference,  inactivity  or  instability. 

As  symptoms  of  the  accompanying  disturbance  of  the  vegetative 
processes,  there  are  often  gastric  disturbances,  manifest  in  anorexia 


203         GENERAL  PATHOLOGY  AND  THERAPY  OE  INSANITY. 

or  desire  for  foods  and  drinks  (alcohol)  previously  nndcsirod  by  the 
individual. 

As  expressing  the  disturbance  of  function  in  the  nervous  centers 
especially,  there  is  manifest  a  general  feeling  of  discomfort  like  that 
■which  occurs  shortly  before  the  outbreak  of  a  severe  febrile  disease :  a 
feeling  of  bodil}'  ■weakness,  exhaustion,  sensory  and  sensorial  hyperes- 
thesia, aura-like  feelings  of  heat.  Very  early  the  change  in  the  psy- 
chic content  makes  itself  manifest  in  an  alteration  of  Iho  glance,  the 
mien,  and  the  attitude. 

Even  though  these  prodromal  symptoms  are  more  or  less  common 
to  all  cases  of  chronic  insanity  that  have  developed  out  of  a  previously 
healthy  personality,  yet  the  nature  of  the  prodromal  symptoms  in  their 
furtlior  course  of  development  depends  upon  the  nature  of  the  special 
form  of  disease  that  is  evolved  {vide  "Special  Pathology"). 

The  transition  to  the  acme  of  the  disease  in  cases  of  chronic  insan- 
ity is  seldom  sudden,  more  often  gradual,  through  increase  and  intensi- 
fication of  the  prodromal  symptoms. 

Like  other  cerebral  and  nervous  diseases,  chronic  insanity  mani- 
fests an  alternation  of  remissions  and  exacerbations. 

The  intensification  and  diminution  of  the  disease  are  to  be  referred 
in  part  to  the  states  of  changing  excitability  of  the  nervous  central 
organ  in  response  to  the  influence  of  the  pathologic  process  (tempo- 
rary exhaustion,  increased  excitability  due  to  summation  of  stimuli), 
to  episodic  ])benomena  occurring  in  the  disease-picture  (precordial 
anxiety  in  melancholia) ;  and  possibly  these  alterations  may  be  in  part 
due,  also,  to  external  cosmic  conditions.  Intercurrent  physical  proc- 
esses, too,  like  the  almost  regular  exacerbations  that  occur  in  tainted 
individuals  and  those  subject  to  uterine  disease,  at  the  time  of  men- 
struation, are  here  of  influence. 

In  many  cases  of  melancholia  and  mania  and  in  paralytic  and 
senile  dementia  there  is  sometimes  a  strictly  typic  and  periodic  alterna- 
tion of  the  symptoms,  or  of  the  series  of  symptoms,  occurring  daily, 
or  at  intervals  of  several  days,  ■which  is  almost  always  of  bad  omen. 
Just  as  the  development  of  chronic  insanity  is  slo^w,  so  is  recovery  from 
it  gradual  and  by  successive  stages,  the  remissions  becoming  more  and 
more  marked  and  noticeable.  The  mental  improvement  may  coincide 
■with  that  of  the  somatic  functions  (nutrition,  sleep,  return  of  the 
menses,  etc.)  ;  it  may  follo^w  it  or  in  rare  cases  precede  it.  The 'inten- 
sity and  number  of  the  symptoms  diminish;  any  delusions  that  are 
present  become  ■weaker,  more  fragmentar}^  and  are  shaken  by  the 
patient's  rea^wakening  juclgment;  hallucinations  and  illusions  become 
less  frequent  and  less  distinct.     Inclination  to  work  aiid  to  resume 


COURSE,  DURATION,  TERMTKATTDN,  AND  PROGNOSIS.         pJKi 

former  habits  reappears.  However,  it  is  often  only  after  repeated 
recrudescence  and  after  overcoming  conditions  of  mental  torpor  and 
physical  exhaustion  that  the  former  personality  is  at  length  re-estab- 
lished. 

Consideration  of  the  general  course  of  insanity  brings  out  the 
interesting  fact  that  there  are  some  psychoses  which  present  a  pro- 
gressive course,  and  others  which,  after  they  have  reached  their 
height,  remain  stationary,  save  for  sliglit  variations,  and,  no  matter 
how  long  they  continue,  do  not  end  in  so-called  states  of  secondary 
mental  weakness.  This  is  true  of  certain  constitutional  affective 
psychoses  (constitutional  melancholia)  of  a  reasoning  character,  and 
also,  to  a  certain  extent,  of  the  various  forms  of  paranoia. 

The  psychoses  presenting  a  progressive  course  may  be  typic  or 
atypie. 

,  The  first  (vesania  typica — Kaulbaum)  occur  only  in  individuals 
devoid  of  a  high  degree  of  nervous  taint.  They  begin  with  melan- 
cholia, which  passes  into  mania,  ending  either  in  recovery  or  a  state 
of  secondary  mental  weakness  {vide  "  Secondary  Delusional  Insanity,^' 
"Dementia^').  Thus,  these  various  forms  are  but  different  stages  of 
one  typic  disease  (psychoneurosis). 

Combined  Psychoses. — A  newly  recognized  fact  that  is  impor- 
tant for  a  clinical  understanding  of  many  cases  is  that  other  forms  of 
insanity  may  comi^licate  one  form  already  jDresent,  in  which  case  two 
or  more  forms  of  disease  combined  may  run  their  courses,  each  undis- 
turbed by  the  others.  In  such  a  case,  of  course,  there  is  nothing  like 
the  alternating  pictures  presented  by  a  circular  psychosis,  or  a  psychosis 
taking  the  place  of  a  vesania  typica,  or  the  phases  of  a  complicated 
disease-picture  like  paralytic  dementia;  but  there  is  the  independent 
and  simultaneous  existence  of  two  or  more  forms  of  disease  in  the  same 
patient. 

Aside  from  the  psychoses  that  are  developed  on  the  basis  of  a  pre- 
existing imbecility,  moral  insanity,  or  acquired  mental  weakness  (eases  by 
Siemens),  cases  taken  from  literature  and  experience  may  be  mentioned: — 

1.  Cases  of  paranoia  with  episodic  menstrual  insanity  (personal  observa- 
tion) ;  paranoia  with  paralysis  (Billod)  ;  masturbatory  paranoia  with  develop- 
ment of  paralysis  (Hostermann)  ;  three  cases  of  paranoia  with  paralysis; 
paralysis  Avith  hallucinatory  paranoia  (two  cases,  personal  observations) ; 
paranoia  with  intercurrent  melancholia,  and  one  with  periodic  mania  (per- 
sonal observations). 

2.  Epileptic  insanity  with  non-epileptic  mental  disturbance  (Magnan). 
(Epileptic  insanity  with  postepileptic  delirium,  and  paranoia  with  delusions  of 
persecution  and  grandeur.)  (The  epileptic  disturbance  disappears  under  treat- 
ment with  potassium  bromide.)  Epileptic  and  circular  insanity  (personal 
observation)  j    epileptic  insanity  with  imperative  ideas  and  alcoholic  delusions 


204         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(Magnnn);  ei^ileptic  insanity  with  later  development  of  melancholia  and 
akoholic  delusions  (Magnan);  epileptic  and  paralytic  insanity  (Westphal) ; 
epileptic  insanity  and  paranoia  (Gnaiik)  ;  epileptic  delirium  and  delirium 
tremens  (personal  observation,  and  Magnan).  Wlion  memory  of  the  events 
of  the  epileptic  delirium  fails,  that  for  the  events  of  tlie  delirium  tremens 
may  still  be  present. 

3.  Psyclioses  and  alcoholic  insanity  (quite  aside  from  tliose  cases  wliere 
tlie  fundamental  picture,  as  of  mania  or  melancholia  or  paralysis,  is  colored 
and  influenced  by  alcoholic  excesses)  ;  chronic  hallucinatory  paranoia  and  alco- 
holic delirium  (^lagnan)  ;  di})somania,  and  delirium  tremens  (Magnan).  Here 
it  is  impossible  to  enter  into  a  consideration  of  the  forced  explanations  and 
hypotheses  put  forward  by  Magnan.  The  relation  is  clearest  where  psychoses 
are  combined  witli  alcoholic  insanity. 

In  cases  of  chronic  insanity  that  recover  the  duration  of  the  dis- 
ease is  months  or  3'ears.  The  duration  of  the  stage  of  complete  devel- 
opment is  not  dependent  on  the  length  of  the  prodromal  stage;  on 
the  contrar}^  the  period  of  convalescence  nsually  bears  a  time-relation 
to  the  duration  and  intensity  of  the  acme  of  the  disease. 

Chronic  insanity  maj''  end  in  recovery/  stationary  or  progressive 
states  of  mental  weakness,  intermissions  (latency  of  symptoms),  or 
death.  Eecovery  is  frequent  in  the  psj^choneuroses.  If  this  does  not 
occur,  then  there,  results  a  state  of  so-called  mental  wealcaess. 

Intermissions  are  not  infrequent  in  paranoia.  A  fatal  result 
may  be  dne  to  the  advance  of  the  pathologic  process  to  vital  centers 
(paralytic  dementia,  acute  delirium,  senile  dementia),  or  it  may  folloAV 
indirectly  upon  exhaustion  or  inanition  dne  to  the  disease;  in  other 
cases  death  may  be  caused  by  tuberculosis  developed  as  a  result  of 
insufficient  nutrition  and  imperfect  respiration;  or  :^uicidi^  or  acci- 
dent may  intervene  to  bring  the  end. 

(b)   Chronic  Insaniltj  in  ilie  Form  of  Periodic  A  If  (ids. 

The  fundamental  cereln-al  disease,  thongli  continuously  present  in 
such  cases,  like  the  manifestations  of  interjnittcnt  fever,  expresses 
itself  in  recurring  paroxysms  of  mental  disturbance  (usually  mania, 
less  frequently  melancholia,  or  a  combination  of  both  in  so-called  cir- 
cular insanity).  In  contrast  with  the  development  of  a  chronic  and 
non-periodic  psychosis,  in  these  cases  the  outbreak  is  sndden,  the  height 
of  the  disease  is  quickly  attained,  and,  if  at  this  stage  remissions  are 
not  marked,  the  attack  may  end  quite  suddenly.     Prodromal  symptoms 


^Formerly  such  recoveries  were  often  thought  to  take  place  with  so-called 
ciitical  excretions;  but  these  are  nothing  more  than  the  signs  of  the  re-estab- 
lih^iment  of  the  trophic  and  secretory  functions  of  the  body  following  upon 
the  recoverv  from  the  brain  disease. 


COURSE,  .Dl'LWnoN,  'ri';i;  M  INA'lION,  AM)   riKXJNOSIS.         205 

oi'  the  a^jproacliing  ontl)r-eak  may  be  entirely  wanting,  or  they  nuiy 
precede  it  by  only  a  very  brief  period.  When  such  symptoms  are  pres- 
ent they  vary  extremely  in  different  cases,  but  are  quite  typic  for  the 
single  case,  conii)arabl(!  oÜcn  with  the  aura  of  epileptic  attacks.  For 
the  most  part,  they  consist  of  congestive  symptoms,  sleeplessness,  and 
irritability;  sometimes  there  is  depression  and  feelings  of  anxiety, 
headache,  neuralgia,  paralgias,  gastric  disturbances,  or  obstipation. 

With  reference  to  the  development  of  the  symptoms  in  detail  and 
their  content,  the  course  of  each  paroxysm  is  decidedly  similar  and 
typic  of  all  the  others,  presenting  at  most  only  variations  of  intensity. 
With  the  disappearance  of  the  paroxysm  there  is  an  immediate  restora- 
tion of  the  former  j^ersonality ;  or,  if  the  attack  has  been  intense  and 
of  long  duration,  recovery  may  take  place  after  a  correspondingly 
prolonged  period  of  exhaustion.  The  duration  of  the  single  attack 
may  be  weeks  or  months.  The  intervals  between  attacks  may  vary 
from  weeks  to  months  or  years. 

It  is  in  no  sense  strictly  typic,  since  varying  internal  and  external 
conditions  are  of  influence.  The  intensity  of  the  attack  is  also  to  be 
considered,  for  after  an  attack  of  especial  violence  the  next  outbreak 
is  usually  postponed.  It  is  customary  to  call  the  intervals  between 
the  attacks  lucid  intervals,  but  they  are  never  strictly  so.  By  the 
side  of  the  nervous  symptoms  of  the  fundamental  disease  mental 
symptoms  (irritability,  variability  of  humor)  are  not  wanting,  and 
mental  weakness  soon  appears  as  a  lasting  alteration. 

Aside  from  their  longer  duration  in  general,  these  intervals  differ 
from  an  intermission  in  that  in  the  latter  the  psychosis  begins  anew 
in  the  new  attack  at  the  point  where  it  ceased  at  the  beginning  of  the 
latent  condition;  whereas  in  the  periodic  psychoses  the  whole  symp- 
tom-complex of  the  attack  runs  its  course  again  from  the  beginning. 
They  differ  from  a  relapse  in  that  the  new  attack  is  clinically  different 
from  the  first,  while  the  periodic  attack  is  stereotyped  and  similar  to 
the  first  in  every  detail;  and,  besides,  in  the  interval  the  state  of  mind 
is  not  perfectly  free,  but  rather  presents  traces  of  the  fundamental  dis- 
ease that  has  become  latent  only  to  a  certain  extent.  The  general 
course  of  periodic  insanity  varies.  In  a  very  few  cases  the  attacks 
cease  to  occur,  either  spontaneously  or  under  the  influence  of  some 
severe  constitutional  disease  (typhoid).  If  this  happen  at  a  time  be- 
fore the  frequently  recurring  attacks  have  induced  a  state  of  mental 
weakness,  the  result  is  recovery;  but  more  frequently  the  attacks  cease 
only  after  a  state  of  mental  weakness  has  become  established,  and  more 
frequently  still  the  latter  occurs  without  cessation  of  the  attacks; 
indeed,  sometimes  the  attacks,  with  the  establishment  of  mental  Aveak- 


ooo  (iEXKRAL  rATlI(tT.Or;Y  AXP  T1I1^1^\^Y  (W  INSANITY. 

uess,  become  longer  and  longer,  until  they  How  into  one  another  and 
finall}'  form  a  continuous  insanity  in  which  the  continually  recurring 
attacks  are  only  to  be  distinguished  as  exacerbations. 

2.  Transitouy   Lnsaxity. 

Tn  contrast  witli  tlio  foriiis  of  insanity  that  nnniiro  months  or 
years  to  run  their  course  are  certain  psychopathic  states  characterized 
by  the  fact  that  they  last  but  a  few  hours  or  days. 

In  these  cases  the  sufhlcn  heginning,  the  rapid  attainment  of  the 
height  of  the  disease,  with  only  slight  variations  of  intensity,  and  the 
sudden  and  critical  end  of  the  attack,  with  the  immediate  restoration 
of  the  former  mental  state,  combine  to  make  a  marked  distinction 
between  this  and  the  usual  forms  of  chronic  insanity,  in  which  only 
certain  periodic  forms  resemble  transitory  insanity.  Besides,  the  lat- 
ter is  characterized  by  the  deeper  disturbance  of  consciousness  during 
the  whole  of  the  attack,  while  defects  of  memory  are  never  wanting, 
and  all  the  features  of  the  picture  present  delirious  characteristics. 
The  explanation  of  these  peculiarities  of  the  course  and  nature  of 
transitory  insanity  is  to  be  found  etiologically  in  part  in  the  fact  that 
it  is  in  reality  a  reactive  manifestation  to  powerful  influences  affecting 
the  brain  temporarily  (disturbances  of  the  circulation,  poisons,  emo- 
tions, fever).  Moreover,  congenital  disorders  of  development  or  ac- 
quired functional  anomalies  may  facilitate  or  intensify  the  effect  of 
these  injurious  influences.  Frequently  in  these  cases  the  brain  is  one 
that  reacts  abnormally  in  its  vasomotor  functions,  and  this  abnormal 
form  of  reaction  (vascular  spasm  or  paralysis  spreading  over  a  large 
area)  may  be  congenital  or  an  hereditary  anomaly ;  or  it  may  have  been 
acquired  as  a  result  of  brain  disease,  injury,  lues,  focal  disease  of  the 
brain,  chronic  alcoholism,  exhaustion,  etc.,  and  thus  be  one  of  the 
symptoms  of  a  complicated  cerel)ral  and  nervous  disease.  Under  all 
circumstances  it  is  necessary  to  insist  clinically  that  transitory  insanity 
is  a  s}Tnptomatic  disease-picture.  In  the  individual  case  it  is  always 
necessary  to  try  to  refer  the  outbreak  to  the  special  neurosis  or  cere- 
bral disease  that  causes  it.  Pathogenically  cases  of  transitory  insanity 
may  be  referred  (1)  to  sudden  alterations  of  blood-pressure  and  blood- 
distribution  brought  about  by  vascular  spasm  or  paralysis  (transitory 
mania,  transitory  states  of  fear,  pathologic  affects)  ;  (2)  to  sudden 
and  marked  disturbances  of  the  nutrition  of  the  brain  as  a  result  of 
qualitative  changes  of  the  blood,  dependent  either  upon  the  presence 
of  foreign  material  or  the  products  of  retrograde  metamorphosis,  or 
the  absence  or  deficiency  of  certain  normal  constituents  (toxic  delir- 
ium and  inanitJDn-delirium),. 


COURSE,  DURATION,  TERMINATION,  AND  rROONOSIS.         207 

The  forms  of  disturbance  of  consciousness  in  transitory  insanity 
may  be  states  of  somnolence,  sopor,  stupor,  and  semiconsciousness. 
Upon  this  basis  of  consciousness  gravely  disturbed  by  anomalies 
of  the  circulation,  blood-pressure,  or  nutrition,  even  to  the  extent  of 
producing  transudative  changes,  various  symptoms  of  irritation — in 
the  form  of  hallucinations,  delusions,  fears,  and  psychomotor  excite- 
ment— may  arise.  These  are  accompanied  by  other  reactive  anomalies 
of  feeling.  Thus  there  arise  a  great  number  of  clinical  pictures, 
differing  because  of  peculiar  grouping  of  symptoms.  The  states  of 
neurasthenic,  epileptic,  and  hysteric  transitory  insanity,  though  they 
belong  here,  will  be  fully  treated  in  chapters  on  special  pathology, 
because  they  present  special  disease-pictures.  Toxic  delirium  and  the 
delirium  of  fever  and  inanition  have  been  considered  in  the  section  on 
the  causes  of  insanity.  There  then  remain  to  be  described  here,  as 
forms  of  transitory  insanity,  transitory  mania,  transitory  fear,  patho- 
logic affects,  and  abnormal  states  of  reaction  to  alcohol. 

(a)   Transitory  Mania. 

Modern  science  applies  this  term  to  a  form  of  mental  disturbance 
affecting  individuals,  sound  both  before  and  immediately  after  the 
attack,  which  begins  suddenly  and  passes  into  recovery  through  a  deep 
sleep,  with  profound  disturbance  of  consciousness  during  the  whole 
duration  of  the  attack,  so  that  there  is  not  the  slightest  memory  of  the 
events  of  the  time  of  the  mental  disturbance.  This  period  forms  an 
actual  hiatus  in  the  continuity  of  consciousness.  Upon  the  founda- 
tion of  this  profound  disturbance  of  consciousness  there  are  manifes- 
tations of  mental  excitation  (delusions,  false  sense-perceptions,  motor 
anomalies)  which  lend  to  the  concrete  clinical  picture  the  features  of 
furibund  mania  in  one  instance;  in  another,  those  of  hallucinatory 
delirium.  The  term  mania  is  little  suited  to  such  a  disease-picture, 
which  is  certainly  much  more  like  delirium  than  mania,  and  at  most 
it  resembles  mania  only  in  the  occasional  presence  of  the  symptoms 
of  the  rapid  succession  of  ideas  and  aggressive  and  essentially  organic 
and  involuntary  motor  activity. 

The  whole  condition  presents  the  features  of  an  intense  cerebral 
irritation  affecting  the  sensory,  ideational,  and  motor  centers, 
suspending  consciousness.  This  cerebral  irritation  is  caused  b}^  an 
intense  congestive  cerebral  hyperemia;  at  least  the  attack  is  ushered 
in  by  manifestations  of  cerebral  congestion  (vertigo,  headache,  a 
feeling  of  being  stunned,  which  may  even  reach  the  intensity  of  an 
apoplectiform  attack),  irritability,  sensibility  to  light  and  noises; 
^^nd  similar  symptoms  are  present  during  the  outbreak  (congested. 


20S  GENERAL  PATTIOLOaY  AND  THERArY  OF  INSANITY. 

ieverish  head;  injected  coiijuialiva;  lull,  soi't  carotid  [uilso).  Other 
signs  of  cerebral  irrilalioii  are  sometimes  observed  in  the  form  of 
salivation,  grinding  of  the  teeth,  and  partial  tonic  and  climic  mani- 
festations of  spasm.  The  height  of  the  outbreak  is  r;i|)i(lly  attained 
after  biMcf  initial  symptoms;  scH'-cM^nsciousness  is  lost,  and  the 
jiatient  l)ecomes  delirious  and  ra\  ing.  The  content  of  the  (h'lusions 
ami  hnliiicinations  is  nuiinly  of  a  frightful  character,  tliongli  some 
pleasant  delusions  are  interspersed.  The  agitation  of  the  patient, 
who  is  devoid  of  consciousness  of  self,  is  unbounded  and  purposeless, 
partly  as  reaction  in  T('s})oiise  to  the  delirious  and  hallucinatory  phe- 
nomena, and  partly  as  expression  of  the  intense  irritation  of  the 
psychomotor  centers.  Any  reflex  in  the  nervous  paths  of  speech  finds 
expression  in  inai-ticulate  howling  and  shrieking;  oidy  now  and  then 
in  the  incoherent  flight  of  ideas  are  disconnected  words  and  sentences 
to  be  distinguished. 

Kespiration  and  circulation  are  increased  with  the  intense  jacti- 
tation, and  the  patient  is  often  actually  bathed  in  sweat.  After 
half  an  hour  or  a  few  hours  the  raving  decreases,  the  pulse  and 
respirali(ui  hecome  normal,  and  the  exhausted  patient  sinks  into  a 
sleep,  out  of  which  he  awakes,  after  a  few  hours,  completely  lucid. 
In  a  few  cases  after  sleep  has  once  occurred  there  is  a  recrudescence 
of  a  paroxysm. 

At  most,  for  some  hours  after  the  attack  there  are  traces  of 
the  hyperemia  that  has  not  yet  entirely  passed  away  (vertigo,  head- 
ache), and  the  exhaustion  and  great  need  of  sleep  that  might  be 
expected  after  the  paroxysn\. 

Youth,  plethoric  constitution,  choleric,  irritable  temperament, 
and  tendency  to  cerebral  congestion  may  be  mentioned  as  predispos- 
ing causes.  The  latter  tendency,  as  a  sign  of  diminished  resistive 
power  of  the  vasomotor  system,  may  be  due  to  congenital  condi- 
tions, or  may  be  acquired  as  a  result  of  excesses,  disease,  repeated 
labors,  head  injuries,  lues,  or  continued  cares  and  anxieties. 

Among  the  influences  that  excite  the  attack  are  states  of  emo- 
tional excitement  (anger),  excesses  in  drink,  confinement  in  a  close 
and  hot  atmosphere,  and  the  heat  of  the  sun, — all  of  which  tend  to 
induce  vascular  paralysis. 

Genuine  cases  of  transit(UT  mania  have  thus  far  only  been  ob- 
served as  beginning  in  the  Avaking  state.  An  attack  beginning 
immediately  on  awaking  from  sleep  must  raise  the  suspicion  that  it 
is  of  the  nature  of  an  epileptic  delirium.  The  same  suspicion  must 
be  entertained  when  relapses  occur.  These  occur  but  very  infre- 
quently in  genuine  tiansitory  mania.     This  disease  is,  under  all  cir- 


COUKSE,  DURATION,  TERMINATION,  AND  RROONOSIS.         209 

cumstances,  very  infrequent,  and  the  majority  of  tlie  cases  that  are 
classed  under  this  head  in  literature  must  be  regarded  as  of  an.  epi- 
leptic nature,  and  the  attacks  should  be  interpreted  as  epileptic 
equivalents.  Even  pathologic  affects — abnormal  reaction  to  alcohol, 
melancholic  ecstasy,  hysteric  delirium,  and  attacks  of  ordinary  acute 
and  angry  mania — have  often  been  erroneously  called  transitory 
mania. 

With  reference  to  diagnosis,  it  is  necessary  to  insist  on  the  fol- 
lowing characteristics:  the  sudden  beginning  of  the  disease  in  indi- 
viduals mentally  sound  both  before  and  after  the  attack,  and  par- 
ticularly in  those  free  from  epilepsy;  the  critical  termination  in  a 
deep  sleep ;  the  profound  disturbance  of  consciousness,  with  complete 
subsequent  defect  of  memory  for  the  events  of  the  attack;  and  the 
sjanptoms  of  intense  congestion  of  the  brain  which  usher  in  and 
accompany  the  disease-picture. 

Anatomically  the  whole  group  of  symptoms  may  be  explained 
as  the  result  of  an  intense  and  transitory  congestion  of  the  cerebral 
cortex. 

The  prognosis  is  favorable.  Termination  in  apoplexy  or  inflam- 
mation of  the  brain  has  never  yet  been  observed.  The  great  infre- 
quency  of  relapses  has  already  been  luentioned. 

The  treatment  consists  of  restraint  of  the  patient,  who  is  very 
dangerous  both  to  himself  and  others,  and  the  promotion  of  sleep  by 
chloral  hydrate,  which  in  this  condition  can  hardly  be  administered 
in  any  other  way  than  by  enema.  The  hypodermic  administration 
of  ergotine  and  duboisine  sulphate  is  also  worth  a  trial. 

Case  2. — Transitory  mania  due  to  caloric  influences. 

]\Irs.  N.,  aged  36.  Aside  from  infrequent  attacks  of  migraine,  she  had. 
never  been  ill.  Moderate  manner  of  life;  not  sensitive  to  heat;  of  a 
healtliy  family  and  without  epileptic  or  epileptoid  antecedents.  For  a  fort- 
night she  had  sufl'ered  with  a  severe  cold  in  the  head  and  catarrh  of  the 
trachea.  November  25,  1877,  she  felt  chilly  in  the  evening  and  had  a  very  hot 
fire  made  in  the  large  iron  stove  in  her  room.  About  11  o'clock  at  night  she 
suddenly  felt  as  cold  as  ice,  and  then  burning  hot,  and  she  felt  the  blood 
mount  to  her  head.  She  became  delirious  and  violently  excited,  sang  songs, 
and  ran  about  in  the  room  seeking  her  children.  Suddenly  she  became  fright- 
e)ied  and  raving.  The  physician,  Avho  was  called  in  about  midnight,  found  the 
room  at  a  temperature  of  30°  R.  The  patient  was  in  a  state  of  furibund  rav- 
ing, crying  that  her  head  was  to  be  cut  off;  she  frothed  at  the  mouth  and 
raved,  a  prey  to  intense  terror.  At  times  she  laughed,  sang,  and  rhymed. 
Her  head  was  hot  and  red,  the  pupils  dilated,  and  reflex  excitability  was  in- 
creased. The  physician  administered  0.03  gram  of  morphine  by  injection,  with- 
out eflFect.  Only  toward  morning  did  the  patient  fall  asleep,  and  after  some 
hours  she  awoke  perfectly  lucid,  and  tried  to  account  for  the  surroundings  of 


010  GENERAL  PATHOLOCiY  AND  THKI^\rY  OF  INSANITY. 

the  hospital.  Her  temperature  was  subnürnial.  She  had  not  the  slightest 
knowledge  of  \vliat  had  liappened.  She  only  renienibered  that  she  had  fallen 
asleep  with  a  feeling  of  hi-at.  She  vomited,  felt  exhausted  and  dizzy  (mor- 
phine). She  had  eomplelely  reeovered  by  the  27th.  Aside  from  the  catarrhal 
troubles  uientioned  the  patient  presented  notiiing  abnormal. 

(h)   Tran^ilurtj  Stales  uf  Fear. 

States  of  transitory  insanity  occur  in  w  liicli,  with  tlic  ureat  dis- 
turbance of  conscionsness,  the  patient  is  troubled  with  intense  feel- 
ings of  fear  and  ideas  of  threatening  danger.  Such  conditions  may 
last  honrs  or  days.  Whether  memory  for  the  time  of  the  attack  be 
summary  or  wanting  depends  upon  the  extent  to  which  consciousness 
is  disturbed.  The  state  of  fear  may  present  the  most  varied  degrees 
of  intensity,  from  a  simple  anxiety  to  inhibition  of  all  the  mental 
activities.  At  the  height  of  the  disease  frightful  hallucinations 
(auditory  and  visual)  and  terrifying  ideas  of  threatening  danger,  in 
which  the  feeling  of  fear  finds  its  concrete  outlet,  are  seldom  want- 
ing. As  a  result  of  the  fear  and  delirium,  motor  impulses  arise  that 
may  pres'ent  all  degrees  of  intensity  from  simple  motor  unrest  to 
violent  acts  of  desperation  directed  against  the  source  of  threatened 
danger. 

Intense  sensations  of  fear,  felt,  for  the  most  part,  in  the  precor- 
dial region,  with  profound  disturbance  of  consciousness,  and  lasting 
minutes  or  hours,  with  stormy  reflex  mental  activity  as  a  result  of 
the  state  of  fear,  are  called  rapt  us  melanckoliciis.  Since  this  condi- 
tion occurs,  for  the  most  part,  as  an  episodic  manifestation  in  melan- 
cholia, it  will  be  described  later  under  that  heading.  In  this  place 
we  are  concerned  only  with  independent  states  of  transitory  fear  in 
persons  sound  mentally,  both  before  and  after  the  attack.  T\w. 
states  of  petit  mal,  which  occur  in  epileptics  and  resemble  this  condi- 
tion symptomatically,  will  be  described  under  the  heading  of  "Special 
Pathology ^^  {vide  "Epileptic  Insanity ^^). 

In  the  transitory  states  of  fear  we  must  also  insist  upon  their 
symptomatic  significance,  and  seek  their  pathogenic  explanation  in 
acute  disturbances  of  the  circulation  of  vasomotor  origin.  In  many 
cases  there  are  symptoms  of  cerebral  anemia  which  precede  and 
accompany  the  attack;  and  the  symptoms  of  vascular  spasm  in  those 
arteries  that  are  open  to  examination  make  it  seem  probable  that 
similar  functional  disturbances  simultaneously  affect  the  ccreljral 
vessels. 

The  predisposing  causes  of  transitory  states  of  fear  are  neuro- 
pathic constitution,  and  not  infrequently  the  marked  neuroses: 
liysteria,  hypochondria,  and  neurasthenia.     The  latter  is  especially 


COURSE,  DURATION,  TERMINATION,  AND  I'IJ,0(iNOSIS.         211 

important  where  it  is  clue  to  masturbation.  Puberty,  pregnancy, 
lactation,  and  the  menses  seem  to  increase  the  disposition,  as  do  also 
mental  and  physical  overexertion,  especially  lack  of  sleep. 

As  exciting  causes  may  be  mentioned  emotional  excitement,  loss 
of  blood,  neuralgia,  and  also,  perhaps,  alcoholic  excesses,  gastric 
troubles,  and  smoking  strong  tobacco. 

The  prognosis  is  favorable.  Kelapses  are  not  infrequent.  Dur- 
ing the  attacks  the  patient  is  dangerous  to  others,  and  especially  to 
himself  because  of  his  wish  to  die.  Warm  baths,  injections  of  mor- 
phine, chloral  hydrate,  and  amyl  nitrite  have  the  effect  of  ameliorat- 
ing and  shortening  the  attack. 

Case  3. — Transitory  fear  on  a  neurasthenic  foundation. 

L.,  aged  34,  single,  workman  in  an  iron  foundry,  was  aiTested  by  the 
police  as  he  was  about  to  throw  himself  into  the  river,  and,  being  regarded 
as  insane,  he  Avas  brought  to  the  clinic  in  Gratz.  The  patient  was  confused, 
delirious,  and  mentally  inhibited,  and  he  appeared  overcome.  He  declared  that 
he  was  afraid,  that  he  had  seen  a  crowd  of  drowned  men,  that  he  had  tickled 
one  with  a  straw,  and  that  the  corpse  had  come  to  life  and  taken  hold  of  him. 
He  then  declared  that  he  constantly  saw  a  black  man,  who  seemed  to  be  a 
worker  in  iron,  and  who  followed  him  everyAvhere.  He  said  that  on  that 
account  he  was  afraid,  and  that  the  only  recourse  he  had  was  to  throw  him- 
self in  the  water;  that  a  soldier  had  seized  him  and  brought  him  there.  At 
the  time  nothing  more  was  to  be  learned  from  the  frightened  and  confused 
patient,  who  then  drew  the  covers  over  his  head  to  avoid  the  sight  of  the 
black  enemy,  and  thus  he  passed  the  night  quietly,  but  Avithout  sleep.  On  the 
following  day  (January  8,  18S2)  the  patient  Avas  frightened,  inhibited,  and  hid 
in  bed.  On  the  9th,  after  sleeping  all  night,  his  mien  became  freer,  and  he 
noticed  that  he  Avas  not  at  home,  and  sought  to  find  out  his  Avhereabouts. 
The  phantom  had  disappeareü,  but  the  patient  still  felt  as  if  a  Aveight  Avere 
pressing  on  his  head  and  chest.  He  saAV  everything  as  if  in  a  fog.  January 
10th  the  patient  became  lucid,  and  recognized  his  surroundings,  but  he  com- 
plained that  he  felt  pressure  and  distress  in  his  chest,  and  that  nis  head  felt  as 
if  it  were  in  a  vise.  His  memory  returned  by  degrees.  He  said  that  on  the 
5th,  while  at  Avork,  he  became  afraid.  He  felt  as  if  he  must  run  aAvay.  The 
night  of  the  5th  he  passed  AAäthout  sleep.  The  morning  of  the  6th  he  Avent  to 
Avork  as  usual.  He  had  no  rest  from  his  fears.  About  ten  o'clock  he  returned 
home,  dressed  himself,  and  Avent  into  the  toAvn.  He  Avas  driven  on  Avith  irre- 
sistible force.  He  drank  a  glass  of  beer  in  a  restaurant  and  then  Avandered 
about  in  the  streets,  going  to  a  theater  in  the  evening.  In  the  gallery  he 
became  dizzy,  and  so  he  bought  a  ticket  for  the  orchestra.  HoAvever,  his  fears 
did  not  alloAV  him  to  stay  long  in  the  theater,  and  he  Avandered  about  in  the 
streets  until  he  came  to  the  raihvay  station,  Avhere  he  Avas  taken  Avith  the 
thought,  Avithout  motive,  to  go  to  Vienna.  He  passed  the  night  at  a  hotel, 
the  name  of  Avhich  he  kncAV.  Early  on  the  morning  of  the  7th  the  vision  of 
the  irouAvorker  first  appeared.  He  Avandered  about,  and  remembered  that  he 
saAV  a  funeral  procession,  and  recalled  several  of  the  places  where  he  had  been 
and  the  fact  of  his  arrest.    He  had  no  memory  of  the  events  of  the  8th. 


2\-2  GKXKRAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  patient  was  without  luMcililary  taint,  devoid  of  all  epileptic  ante- 
cedents, and  did  not  drink.  In  18SÜ  he  snUered  with  eholeia  morbus,  and 
later  with  intermittent  fever.  Jle  felt  that  he  was  weakened  by  this  sick- 
ness; previously  he  had  always  been  healthy.  In  his  work  lie  was  much  ex- 
posed to  caloric  inlluenccs,  and  as  a  result  he  had  often  had  di/./incss  and 
headache.  His  work  was  very  laboriouij,  and  besides  he  iiad  to  endure  a  cer- 
tain amount  of  emotional  strain.  For  iluee  weeks  he  hail  felt  increasing 
fatijrue,  and  liad  >!cpt  badly,  having  disturbing  dreams  of  tire  and  of  falling 
over  a  precipice.  Jt  became  more  and  more  dillicult  for  him  to  work;  he 
began  to  tremble  easily,  and  on  rising  in  the  morning  felt  tired  and  depressed; 
he  perspired  even  when  it  was  cool,  and  felt  pressure  in  his  head,  palpitation 
ot  the  heart,  and  precordial  distress.  He  could  not  stand  even  a  small  amount 
of  alcohol,  for  it  made  him  feel  intoxicated.  Eight  days  before  the  attack  he 
flew  into  a  violent  passion  over  an  argument. 

The  patient  was  of  a  medixun  height;  fairly  strong,  but  somewhat 
anemic;  without  fever.  Certain  of  the  spinotis  proces.ses  of  the  dorsal  region 
were  somewhat  sensitive  to  pressure.  The  spleen  was  not  enlarged,  and  the 
functions  of  the  vegetative  organs  were  not  in  any  way  disturbed,  ^lasturba- 
tion  was  denied,  and  there  was  nothing  to  raise  suspicion  of  it.  The  patient 
continued  lucid  and  free  from  fear.  He  continued  to  present  neurasthenic 
symptoms,  Avhich  wea-e  improNed  by  tonic  treatment.  His  sleep  was  still  dis- 
turbed by  awful  dreams.  January  28,  18.S2,  the  patient  was  discharged  recov- 
ered.    There  has  been  no  relapse. 

(c)  Palltulugic  Slales  of  Enioliun. 

Emotions  or  affects  ma}^  become  abnormally  intense  and  require 
an  unnsuallv  long  time  in  subsiding.  Such  conditions  ^\Q  speak  of  as 
pathologic  states  of  emotion.  An  emotional  state  seems  abnormally 
intense  when  the  affected  individual  loses  consciousness  and  his 
motor  acts  lose  the  characteristics  of  voluntary  acts.  Such  a  patho- 
logic affect  may  continue  hours  or  even  days.  Strictly  speaking,  in 
such  a  case  as  this  the  condition  is  no  longer  an  emotional  state,  but 
rather  a  transitory  state  of  insanity  due  to  emotional  sliDck.  Such  a 
condition  causes  more  profound  and  enduring  changes  of  vaseidar 
innervation  than  that  which  accompanies  the  ordinary  emotion;  that 
is,  an  emotion  which  is  not  intensified  to  the  extent  that  conscious- 
ness is  lost  and  quickly  disappears.  In  accordance  with  the  nature 
and  cause  of  the  entotion,  the  disturl)ance  is  accompanied  either  by 
vasomotor  spasm  (fright)  or  by  vasomotor  paralysis  (anger).  The 
widespread  distribution  of  the  disturbance  of  vascular  innervation 
indicates  that  the  vasomotor  centers  are  directly  affected  by  the 
emotional  shock.  Under  all  circumstances  the  distribution  of  blood 
and  blood-pressure  are  subjected  to  a  sudden  and  profound  disturb- 
ance, and  this  fact  explains  the  most  prominent  clinical  sj'mptom, — 
the  profound  disturbance  of  consciousness,  which  may  go  even  to  the 
extent  of  complete  suspension, — with  which  the  subsequent  imperfeC' 


C:OURSK,  DURATION,  TEliMlNA^J'K  )N.  AND   l'i;<)(  ;XOSIS.         213 

tion  of  memory  or  its  complete  failure  for  the  events  of  the  attack 
correspond.  The  conditions  that  favor  the  origin  of  pathologic  emo- 
tions are  multitudinous. 

In  the  first  place^,  the  nature  of  the  emotion  is  important.  Only 
the  depressing  affects  of  fear,  friglit,  and  anger  attain  pathologic 
intensity,  and  that  the  more  easily,  the  more  unexpectedly  the 
emotion  begins,  and  the  more  the  accompanying  idea  ilwciitcns  per- 
sonal interests  (life,  personal  and  sexual  honor). 

But  the  state  of  the  vascular  centers  affected  at  the  time  of  tlie 
emotional  shock  is  decisive  for  the  result.  Their  abnormal  excita- 
bility or  exhaustibility  may  be  either  an  enduring  or  a  temporary 
condition.  As  a  continuous  characteristic,  abnormal  reaction  of  the 
vascular  centers  is  frequently  one  of  the  manifestations  of  an  heredi- 
tary taint  (abnormal  emotional  irritability),  of  an  arrest  of  develop- 
ment of  the  brain  (mental  weakness),  of  a  neurosis  (hysteria,  epilepsy, 
h3''pochondria,  neurasthenia,  chorea,  etc.),  of  an  acquired  state  of 
weakness  of  the  brain  after  apoplexy,  head  injury,  mental  disease, 
etc.,  or  an  existing  cerebral  disease  (beginning  insanity,  chronic 
alcoholism,  cerebral  syphilis,  etc.). 

In  such  conditions  there  is  frequently  at  the  same  time  an  ab- 
normal impressionability  of  the  vascular  system  of  alcoholics  (vide 
"Conditions  of  Pathologic  Keaction  to  Alcohol"). 

Temporary  functional  weakness  of  the  vasomotor  centers  may  be 
induced  by  the  weakening  influence  of  diseases  which  cause  waste, 
pain,  and  loss  of  sleep;  the  puerperal  state,  mental  and  physical 
strain,  lack  of  food,  troubles,  cares,  and  passions.  It  is  also  probable 
that  a  normal  brain  is  capable  of  reacting'abnormally  in  a  pathologic 
emotion,  if  alcoholic  excesses  or  high  external  temperature  coincide 
with  an  emotional  shock. 

The  forms  of  pathologic  emotion  may  resemble  those  of  transi- 
tory mania  (''ira  furor  lirevis" ) ;  or  they  may  take  the  form  of  in- 
hibitory stupor  (due  to  vascular  spasm  or  vascular  paralysis,  with 
subsequent  edema)  or  "confusion."  States  of  confusion  may  present 
slight  degrees  of  difference  dependent  upon  the  episodic  occurrence 
of  hallucinations  and  delusions,  usually  as  partial  after-images  and 
after-effects  of  the  exciting  cause;  or  the  confusion  may  be  uncom- 
plicated— a  dreamy  confusion  of  ideas  Avith  inhibition  of  association 
and  profound  disturbance  of  apperception.  In  this  condition  the  dis- 
turbance of  the  mental  functions  may  be  still  further  increased  by 
aphasia  and  paraphasia  (fright). 

The  termination  of  these  pathologic  emotional  states  usually 
takes  place  suddenl}^,  after  lasting  a  few  hours  or  days.     There  are 


2\[         riKXERAL  PATHOT.OnV  AXD  TTTT:"n\rV  OV  TXSAXTTV. 

cases  wliich  end  in  chronic  insanity  or  in  a  direct  loss  of  miiul  which 
passes  into  permanent  dementia. 

Case  4. — Confnsion,  foUowod  hy  ptnpor,  duo  to  friulit. 

C,  aged  11,  sclioolboy.  ilotlicr  ncnr()|);it  liic;  no  epileptic  antecedents. 
Tlie  patient  developed  ■well,  and  was  nexcr  sick  iinlil  fourteen  nimillis  ai^o. 
At  that  time  Ik;  had  a  fall  with  concussion  of  the  brain,  and  is  said  to 
have  been  unconscious  after  it  for  several  days.  For  some  time  he  had  been 
noticed  to  be  unusually  emotional  and  timid.  On  September  "22,  1880,  his 
father  threatened  to  wliip  him.  At  this  he  was  very  much  frightened,  ran 
away,  and  was  brought  home  later  all  confused  and  disturbed.  After  this  he 
could  do  nothing  more  in  school,  and  understood  nothing  of  what  was  taught. 
While  in  this  condition,  on  the  25th,  he  had  his  ears  severely  bcxed.  After 
tliis  he  became  completely  stuporous,  inhibited  by  fright,  and  stared  straight 
before  him.  On  the  2Gth,  when  the  patient  was  received,  he  was  confused  ami 
would  not  speak.  Pulse,  00  and  very  small;  no  fever.  No  signs  of  degen- 
eracy. His  development  corresponded  with  his  age;  somewhat  anemic.  Left 
to  himself,  he  stood  on  his  head,  covered  his  face  with  his  hands  and  the  bed- 
clothes, or  rolled  about  on  the  floor.  Deep  disturbance  of  consciousness. 
Now  and  then  his  confused  mien  was  enlivened  by  a  smile.  The  pupils  were 
continuously  dilated,  but  reacted.  His  nights  were  quiet.  Until  the  morning 
of  the  30th  the  patient  was  confused  and  hid  himself  in  corners.  On  the  28tli 
and  29th  he  was  salivated  for  some  hours,  and  once  he  tore  his  shirt,  anotKer 
time  his  hat,  looking  into  it  roguishly;  occasionally  he  sang  and  whistled. 
When  asked  about  his  health  he  smiled  cunningly  and  said:  "Don't  know." 
After  a  good  night's  sleep  the  patient  awoke  on  the  morning  of  the  30th  recov- 
ered. He  had  only  a  very  summary  memory  of  the  events  of  the  attack.  He 
could  remember  nothing  of  his  hallucinations  and  delusions.  He  said  he  did 
not  know  what  he  was  doing;  that  he  had  been  foolish.  It  seemed  that  he 
had  awakened  out  of  a  confused  dream.     The  patient  remained  well. 

(d)  States  of  Pathologic  Beaction  to  Alcohol. 

The  reaction  of  the  normal  brain  to  an  excess  of  alcohol  has 
already  been  alluded  to  on  page  3±.  There  are  states  of  pathologic 
reaction  to  alcohol  that  are  not  ordinary  drunkenness,  but  actual 
transitory  insanity. 

The  amount  and  nature  of  the  drink  are  of  subordinate  impor- 
tance; constitutional  and  pre-existing  morbid  conditions  are  in  these 
cases  the  important  elements.  At  any  rate,  the  manner  of  their 
origin  is  not  so  much  directly  chemic  (disturbance  of  the  nutrition  of 
the  ganglion-cells  of  the  cortex — intoxication)  as  dynamic,  through  a 
paralyzing  influence  on  the  vasomotor  centers,  Avith  a  consequent 
condition  of  congestion. 

The  etiologic  factors  are  essentially  the  same  as  those  that 
are  effectual  in  pathologic  emotional  states ;  but  here  the  weakening 
influence  of  continued  alcoholic  excesses  plays  a  prominent  role. 
Aside  from  alcohol,  which  may  play  but  a  relatively  unimportant  role, 


COURSE,  DURATION,  TERMINATfON,  AND  FKOOXOSIS.         21  o 

the  exciting  causes  are  intense  emotions,  fasts,  sleepless  nights,  and 
caloric  influences. 

Delirious  states  of  semiconsciousness  and  haliacinatory  delirium 
occur,  probably  only  after  long-continued  abuse  of  alcohol;  and  also 
similar  states  of  transitory  mania. 

The  states  of  acute  deliririm  call  to  mind  the  grand  mal  of 
epileptics.  After  initial  symptoms  of  alcoholic  intoxication,  more  or 
less  pronounced,  there  develops  a  condition  of  increasing  fear  and 
frightful  auditory  and  visual  hallucinations.  Consciousness  is  extin- 
guished. The  patient  wanders  about,  tortured  by  horrible  fears  and 
a  tumult  of  hallucinations;  he,  as  in  a  dream,  looks  upon  his  sur- 
roundings as  threatening,  and  raves  and  storms  aggressively  at  the 
height  of  his  terror.  States  of  stuporous  remission  may  be  inter- 
posed. After  a  few  hours  or  days  the  patient  comes  to  himself  with 
amnesia  for  all  the  events  of  the  attack. 

With  reference  to  the  differential  diagnosis  of  this  condition 
and  an  ordinary  state  of  drunkenness,  the  following  points  are  to  be 
considered : — 

1.  There  is  a  want  of  relation  between  the  amount  of  alcohol 
consumed  and  its  effect,  because  inner  organic  conditions  or  acci- 
dental influences  induce  a  cumulative  effect. 

3.  The  association  of  cause  and  effect  in  time  is  not  that  ob- 
served in  the  ordinary  state  of  drunkenness.  The  progressive  in- 
crease of  alcoholic  symptoms  is  wanting  here.  The  pathologic  state 
of  intoxication  occurs  immediately  at  the  beginning  of  the  relative 
excess,  or  later  with  the  appearance  of  some  intensifying  influence 
(emotion)  which  increases  the  latent  alcoholic  congestion. 

3,  There  is  also  a  qualitative  difference  from  an  ordinary  drunken 
condition.  There  is  developed  a  more  or  less  coherent  delirium; 
apperception  disturbed  by  hallucinations;  maniacal  symptoms,  with 
impulsive  acts,  outbursts  of  rage,  and  destructiveness.  The  move- 
ments are  not  awkward  and  ataxic,  as  in  drunken  persons,  but  have 
maniacal  features — sure,  powerful,  and  energetic. 

The  profound  disturbance  of  consciousness  corresponds  with  a 
complete  absence  of  memory  for  the  period  of  the  paroxysm.  The 
paroxysm  is  initiated  and  accompanied  by  symptoms  of  cerebral  con- 
gestion (flushing,  headache,  hyperesthesia  of  the  sense-organs). 

Case  5.— Delirious  state  of  semiconsciousness  after  indulgence 
in  alcohol. 

P.,  aged  30,  ironworker,  drinker.  Some  years  before  he  had  had  a  severe 
attack  of  typhoid  fever,  and  since  then  he  had  shown  a  remarkable  intolerance 
of  alcohol.     No  epileptic  antecedents. 


21G  CEXF.RAL  IWTHOLOCY  AND  T11E1;A1>Y  OF  INSANITY. 

ilarch  15th,  in  a  circle  of  friends,  he  got  drunk.  Suddenly  he  left  the 
drinking  place,  went  to  the  cashier  of  tlie  works,  and  demanded  an  advance  of 
wages,  threatening  to  hang  himself  if  his  demand  were  not  complied  with. 
AN'hen  he  was  told  to  come  again  in  an  hour,  he  went  home,  made  a  bundle  of 
his  best  clothes,  took  tliem  to  the  saloon-kecijer,  saying:  "There  are  my 
things;  1  am  going  to  liang  myself."  Then  he  ran  out,  climbeil  over  a  seven- 
foot  wall,  tlien  up  a  tree,  and,  fastening  a  rope  tliere,  he  iiung  himself.  He 
was  followed  and  cut  down,  and  thougli  he  had  already  become  asphyxiated, 
he  was  restored  to  life.  Thereupon  he  raved  and  stormed  and  could  scarcely 
be  approached,  and  it  was  with  difficulty  that  he  was  secured.  Un  the  10th 
he  became  quiet  and  exhausted,  and  in  this  condition  he  was  brought  to  the 
asylum.  There  he  came  to  himself  in  a  state  of  astonishment  on  the  18th. 
lie  knew  absolutely  nothing  of  the  events  of  the  period  that  had  elapsed  since 
he  had  left  the  saloon.  On  liis  neck  there  was  the  mark  of  a  rope.  The 
patient  was  mentally  exhausted,  complained  of  headache,  and  there  was 
tremor  of  the  fingers  and  tongue,  and  dilated  pupils.  Excepting  a  gastric 
catarrh,  there  was  no  vegetative  anomaly.  By  the  2Gth  all  symptoms  had 
disappeared,  and  the  patient  left  the  asylum. 


CHAPTER  II. 
Morbidity.    Important  Intercurrent  Diseases. 

The  morbidity  of  the  insane  is  greater  than  that  of  the  sane  at 
the  same  period  of  life. 

This  is  partly  due  to  the  fact  that  many  insane  persons  are 
afüicted  with  a  neuropathic  constitution  which  reduces  their  power  .to 
withstand  external  injurious  influences;  partly  to  the  fact  that  the 
mental  disturbance  induces  irregularity  in  taking  food,  irregularity 
of  life,  and  directly  or  indirectly  profound  disturbances  of  nutrition 
(anemia)  through  its  influence  on  the  vegetative  organs,  and  renders 
the  patient  insensible  to  external  injurious  influences  (cold,  pain),  and 
thus  leads  him  to  expose  himself  more.  In  melancholic  patients,  too, 
the  respiration  is  often  imperfect,  and  the  decarbonization  of  the 
blood  is  thus  defective;  also  in  dementia  physical  exercise  is  fre- 
quently insufficient.  Then,  where  the  insane  are  not  cared  for  in 
hospitals,  there  is  the  traditional  neglect  in  their  care,  or  the  opposi- 
tion on  the  part  of  the'  patient;  on  the  other  hand,  in  asylums, 
usually  overcrowded,  there  is  to  be  considered  the  unhygienic  influ- 
ence of  too  many  patients  housed  in  a  limited  space;  and,  finally, 
it  is  to  be  remembered  that  the  cerebral  disease  may  extend  and 
involve  other  vital  portions  of  the  central  nervous  system.  In- 
sanity does  not  establish  immunity  against  any  other  form  of  disease. 
All  the  acute  and  chronic  maladies  that  affect  the  sane  are  observed 
in  asylums  for  the  insane.     On  account  of  their  lessened  power  of 


COURSE,  DI'RATIOX,  TF.TIMI  XATFON,  AM)   I'KOCJXOSIS.  217 

resistance^,  when  epidemics,  break  out  in  asylums,  tlie  insane  are 
more  easily  attacked  and  the  mortality  is  greater  than  that  of  the 
sane  under  similar  circumstances.  Carcinoma  seems  to  be  somewhat 
less  frequent  in  the  insane  than  in  the  sane. 

The  recognition  of  intercurrent  somatic  diseases,  even  in  severe 
forms,  is  a  matter  of  peculiar  dilliculty,  because  the  disturbance  of 
consciousness  and  the  analgesia  of  many  patients  do  not  permit 
them  to  appreciate  the  disorders  of  general  feeling.  In  such  patients 
diagnosis  is  still  more  difficult  than  in  children,  who  will  at  least 
react  to  pain.  Thus  it  happens  that  typhoid,  pneumonia,  and  other 
severe  diseases  run  their  course  Avith  the  patients  Avalking  about,  and 
they  are  discovered  only  when  the  patient  is  about  to  die  or  on  the 
postmortem  table.  Since,  for  the  most  part,  the  patients  are  weak 
and  cachectic,  the  prognosis  is  always  more  unfavorable  than  in  the 
sane. 

Among  the  somatic  aifections  of  the  insane,  constitutional  anemia,  espe- 
cially in  females,  plays  an  important  role. 

Many  of  the  chronic  insane  die  simply  of  anemia  and  marasmus.  Un- 
known trophic  causes,  dependent  upon  the  central  disease  (sympathetic),  must 
be  assumed  to  explain  many  of  these  cases  of  anemia — which  yield  neither  to 
dietetic  nor  medical  treatment,  and  which  begin  before  puberty  and  continue 
through  life. 

Inflammatory  affections  of  the  respiratory  organs  are  very  frequent  and 
important.  Pneumonia  is  the  cause  of  death  in  about  one-sixth  of  the  cases. 
Hypostatic  pneumonia  is  especially  frequent  in  dements  affected  with  maras- 
mus, and  it  is  to  be  referred  to  weak  action  of  the  heart  and  imperfect  respi- 
ration. A  form  of  pneumonia  due  to  vascular  paralysis  dependent  on  the 
cerebral  process  is  frequently  a  cause  of  death  in  paralytics  (Gaye).  Croupous 
pneumonia  is  also  of  frequent  occurrence,  and  its  oi'igin  is  favored  by  the  chill- 
ing to  which  many  patients  are  subjected,  especially  maniacal  persons. 

As  in  the  case  of  the  aged,  pneumonia  in  the  insane  runs  a  latent  course, 
as  a  rule,  without  chill,  cough,  or  expectoration;  so  that  its  presence  is  shown 
only  by  physical  signs.  Loss  of  appetite  and  an  adynamic  condition  are  often 
the  only  outward  signs  of  the  disease. 

Pulmonary  tuberculosis  is  very  frequent  in  asylums.  In  428  fatal  cases 
Dagonet  found  109  cases  of  pulmonary  phthisis.  Hagen's  statistics  also  show 
that  pulmonary  tuberculosis  is  five  times  more  fatal  to  the  insane  than  the 
sane,  but,  at  the  same  time,  that  insanity  is  five  times  as  frequent  in  the 
tuberculous  as  in  those  free  from  that  disease.  The  explanation  of  this  fact 
lies  probably  in  part  in  the  neuropathic  constitution  that  underlies  both 
affections,  but,  for  the  most  part,  in  the  insuflficient  nutrition  of  fasting  pa- 
tients, especially  the  melancholic,  who  at  the  same  time  breathe  imperfectly; 
and,  last,  in  the  unhygienic  conditions  that  prevail  in  overcrowded  asylums. 

Gangrene  of  the  lungs  is  not  infrequent  in  fasting  patients  as  a  result  of 
inanition;  but  it  may  also  be  caused  by  particles  of  food  that  have  found 
their  way  into  the  air-passages  in  unskillful  artificial  feeding  (L.  Meyer). 
Sometimes  it  is  also  one  of  the  results  of  a  septic  process   (decubitus),  and 


oi.v;  CEXRRAL  PATHOT.OnY  AND  TIIKRAPY  OF  TNSAXITY. 

perhaps  to  be  attributed  to  septic  emboli,  la  the  gangrene  of  inanition  the 
course  is  usually  of  such  a  nature  that  it  is  initiated  by  loss  of  flesh,  fever, 
dyspnea,  catarrh,  pain  in  tlie  thorax,  muscular  weakness,  and  cool  extremities. 
Then  there  is  sweating  and  a  pale  skin  and  cyanotic  cheeks.  The  sputa  and 
brtath  become  terribly  otiensive.  The  physical  signs  of  consolidation  of  the 
lungs,  pleuritis,  ami  even  of  pneumothorax  and  pulmonary  hemorrhage  may 
be  found.  Death  then  results  from  anemia.  |iyemia.  piienmuthorax,  or  profuse 
iicmurrhages  in  from  ten  days  to  three  weeks  (Fisohel). 

Intestinal  catarrh  with  catarrhal  erosions  is  not  infrequent  in  the  insane, 
and  sometimes  it  is  the  cause  of  death  (marasmus).  Loss  of  appetite, 
meteorism,  rapid  loss  of  strength,  and  uncontrollable  diarrhea  arc  the  most 
important  symptoms. 

Surgical  aflfections  due  to  self-injury  or  to  injury  at  llie  hands  of  other 
patients  are  frequent  in  the  insane. 

Boils  and  carbuncles  are  not  seldom  the  result  of  infections  and  injuries 
of  the  skin  in  filthy  patients  who  roll  about  in  straw. 

The  introduction  of  foreign  bodies  into  the  orilices  of  the  body  in  silly 
play  or  tivOiinii  ritiv  is  frequent.  Even  articles  used  at  table,  such  as  forks, 
have  been  swallowed  by  insane  patients.^ 

Facial  erysipelas  occurs  often,  due  to  injury  and  uncleanliness  of  the 
nasal  mucous  membrane.  Conjunctivitis  is  often  induced  by  contact  with 
infected  secretions— vu-ine,  vaginal  mucus. 

Decubitus  occurs  as  a  neurotrophic  manifestation,  favored  by  uncleanli- 
ness in  paralytic  and  exhausted  patients. 

Decided  fragility  of  the  bones  is  not  seldom  observed,  especially  in  the 
paralytic  insane.  It  is,  for  the  most  part,  accompanied  by  marked  diminution 
of  the  calcium  salts,  and  is  most  frequently  found  in  the  ribs,  which  when  thus 
affected  may  be  cut  with  a  knife. 

Slight  contusions  under  such  circimistances  are  sufficient  to  cause  frac- 
tures of  the  ribs,  which  not  infrequently  induce  pleuritis. 

Jolly  was  the  first  observer  to  call  attention  to  the  occurrence  of  fat- 
emboli  in  the  vessels  ot  the  lungs  of  excited  patients,  resulting  from  bruises 
and  tears  of  subcutaneous  fat-tissue,  with  dyspnea,  cyanosis,  collapse,  and 
death  residting.  The  autopsy  showed,  on  microscopic  examination,  that  the 
vessels  of  the  lungs  were  filled  with  drops  of  fat  even  as  far  as  their  smallest 
branches.  At  the  seat  of  contusions  where  the  absorption  of  fat  had  taken 
place,  numerous  gangi-enous  or  purulent  points  of  inflammation  were  found. 

Othematoma  (insane  ear)  is  a  remarkable  phenomenon.  It  occurs  most 
frequently  in  the  upper  and  outer  part  of  the  auricular  cartilage;  also  in  the 
fossa  navicularis  and  triangularis;  less  frequently  in  the  concha,  helix,  and 
external  orifice.  The  left  ear  is  more  frequently  affected  than  the  right,  but 
sometimes  both  ears  are  involved.  There  is  a  circimiscribed,  fluctuating, 
bluish-red  swelling,  more  or  less  considerable  in  size,  over  which  the  skin  is 
intact.  It  develops  quickly,  remains  thereafter  for  weeks  or  months  in  a 
stationary  condition,  and  finally  disappears,  leaving  a  deformity  of  the  ear. 
The  phenomenon  is  due  to  the  effusion  of  blood  between  the  perichondrium 


'^The  death  of  a  paranoiac  in  the  Northern  Michigan  Asylum  was  due  to 
tlie  insertion  of  the  wooden  tooth  of  a  garden  rake  in  the  urethra.— Tkans- 


1.AX0U. 


COURSE,  DURATION,  TKRMTKATroy,  AXD  r'i;Or:\T)SIS.  2\0 

and  the  cartilage,  but  aoooiding  to  otlier  observers  (Ondden)  tlie  effusion 
of  blood  takes  place  in  the  separated  cartilage,  which  itself  has  undergone  no 
microscopic  change.  When  the  blood  is  reabsorl)ed  the  perichondrium  shrinks 
and  draws  upon  the  other  parts  of  the  ear,  and  thus  the  deformity  is  induced. 
Since  simultaneously  the  peric-liondriuni  secretes  new  cartilage  upon  its  inner 
surface,  the  cartilage  of  the  ear  becomes  thickened. 

Two  views  are  entertained  with  reference  to  the  origin  of  this  interesting 
abnormality.  A  number  of  observers  regard  the  affection  as  a  neurotic 
dyscrasia.  They  contend  that  othematoma  often  develops  as  result  of  neuro- 
paralytic hyperemia  of  the  ears  (paralysis  of  the  vasomotor  nerves  lying  in 
the  path  of  the  trigeminus)  ;  that  it  rarely  occurs  in  healthy  individuals,  but 
almost  exclusively  in  the  insane,  and  especially  in  the  severe  and  advanced 
stages  of  insanity  (dementia  paralytica,  transitional  states  to  secondary  de- 
mentia), in  which  profound  vasomotor  disturbances  of  the  nerve-centers  are 
present  and  manifest  themselves  in  edema,  ecchymoses,  decubitus,  etc. 

In  such  patients  a  slight  injury,  even  simple  increase  of  blood-pressure, 
is  suflficient  to  induce  effusion  of  blood,  since  the  vessel-walls  have  undergone 
changes  of  nutrition  as  the  result  of  the  general  cachectic  state,  while,  on  the 
other  hand,  in  maniacal  and  epileptic  patients,  who  are  especially  subject  to 
injuries,  othematoma  is  very  infrequent.  It  should  also  be  remembered  that 
othematoma  is  most  frequent  in  paralytic  patients,  where  new  formation  of 
vessels  occurs,  not  only  in  the  brain,  but  also  in  other  organs  as  the  result  of 
neuroparalytic  hyperemia.  Newly  formed  vessels,  however,  offer  but  slight 
resistance  to  external  violence  or  to  an  increase  of  blood-pressure. 

Hoffmann  regards  othematoma  as  a  hemorrhagic  inflammation  of  the 
cartilage  analogous  to  hemorrhagic  pachymeningitis. 

L.  Meyer  found,  as  a  cause  of  othematoma,  small  enchondromas  in  the 
auricular  cartilage,  which  were  often  rich  in  vessels  and  induced  effusion  of 
blood  upon  slight  injury.  He  also  found  it  not  infrequently  in  chronic  diseases 
without  insanity.  In  cases  Avhere  othematoma  occurred  tumors  of  the  auricu- 
lar cartillage  were  always  first  observed,  and  othematoma  which  followed 
always  occupied  the  seat  of  the  enchondroma. 

Other  observers  emphasize  exclusively  the  traumatic  origin  of  othem- 
atoma. In  support  of  this  view  it  is  noted  that  the  auricular  cartilage  is 
ruptured;  that  in  individuals  mentally  sound  violent  mechanical  injury  may 
induce  it,  as  is  shown  by  experiments  and  the  busts  of  Pancratia.sts  with 
deformed  ears;  that  the  left  ear  is  most  frequently  aft'ected  because  it  is 
most  prone  to  injury  by  a  blow  given  by  the  right  hand  of  another:  that  in 
institutions  where  injury  to  patients  and  self-injury  are  prevented,  othem- 
atoma is  extremely  rare.  Stahl  compares  othematoma  with  reference  to  its 
mode  of  origin  with  the  cephalhematoma  of  the  newborn. 

This  vexed  question  is  not  yet  settled.  The  truth  probably  lies  between 
the  two  vicAvs.  If  the  fact  that  severe  mechanical  injury  is  necessary  to 
induce  othematoma  in  the  healthy  is  remembered,  then  it  may  be  concluded 
that  the  insane  possess  at  least  a  predisposition  to  it,  whether  it  be  due 
to  dyscrasia,  disease  of  the  blood-vessels,  or  to  enchondroma.  The  fact  that 
othematoma  occurs  most  frequently  in  the  left  ear  in  itself  proves  nothing 
"with  regard  to  a  traumatic  cause  in  the  aboA^e  sense,  for  other  diseases — ^like 
pneumonia,  neuralgia,  etc. — afl'ect  especially  the  left  side  of  the  body,  which 
in  a  certain  sense  may  be  regarded  as  the  place  of  least  resistance. 


•.'•.)()  Oi:XERAI.   FATHOLOCV   AND  TIIKKAPV   OK   IXSAXITV. 

As  far  as  otlieniatonm  in  tlie  licalthy  is  concerned,  liereat't^er  such  cases 
should  be  examined  with  a  view  to  determine  whether  there  is  not  a  taint. 
One  day  I  made  the  acquaintance  of  a  colleague  whose  left  ear  wa^  deformed 
as  the  result  of  othematoma.  In  his  youtli  tlie  teacher  had  boxed  iiim  on  the 
ear.  My  investigations  sliowed  tliat  there  were  .several  insane  persons  in  liis 
family,  and  tliat  lie  himself  was  an  eccentric,  original,  and  abnormal  man.' 

Experience,  has  shown  tiiat  expectant  treatment  of  othematoma  is  the 
best.  The  occurrence  of  an  analogous  condition  in  the  nasal  cartilage  has 
been  proved  by  Koeppe. 


CHAPTER   III. 
Prognosis  of  Insanity. 

To  :n[AI\:e  a  prognosis  in  a  case  of  insanit}'  is  one  of  the  most 
responsible  duties  of  the  alienist.  It  is  demanded  very  frequentl}^ 
and  for  the  most  various  reasons.  -  Frequently  the  relatives  wish  to 
know  what  the  result  of  the  disease  will  be,  either  owing  to  sympathy 
with  the  i^atient  or  on  account  of  important  financial  interests  (ful- 
fillment of  contracts,  continuance  or  cessation  of  business,  etc.); 
often  officers  of  the  law  demand  an  answer  on  account  of  possible 
necessary  legal  guardianship  or  the  contrary;  or,  in  the  case  of 
officials,  in  order  to  settle  the  question  of  possible  resumption  of 
duty  or  retirement;  in  the  case  of  criminals,  with  reference  to  their 
commitment  to  an  asylum  in  case  of  incurability;  and  finally  in  many 
countries  to  settle  the  question  of  marriage,  or  divorce  when  incur- 
able insanity  constitutes  a  legal  ground  for  separation. 

To  add  to  the  responsibility  there  comes  the  technical  difficulty 
which  depends  upon  imperfect  data  concerning  the  origin,  consti- 
tution, and  previous  life-history,  the  uncertainty  of  pathogenesis,  the 
temporary  latency  of  symptoms;  and  semeiology,  Avhich  scarcely  goes 
further  than  a  collection  of  em^iirically  ascertained  facts.  Thus,  we 
can  but  seldom  be  in  a  position  to  make  a  prognosis  with  certainty, 
and  we  are  forced  to  be  satisfied  with  a  probable  prognosis  which 
borders  upon  certainty. 

Prognosis  may  have  reference  to  the  prohahililij  of  life,  io  cure, 
to  recurrence,  and  to  transmission  of  tlie  disease  to  descendants. 

1.  Pkogxosis  of  Life. 

"With  reference  to  the  prognosis  of  continued  life,  in  general 
it  can  only  be  said  that,  on  the  whole,  insanity  reduces  the  average 
length  of  life.    The  cause  of  this  lies  in  the  greater  mortality  of  such 


^  Many  pugilists  present  this  anomaly.  It  seems  rational  to  conclude 
that  in  the  majority  of  cases  it  is  excited  by  injiuy  and  fa\ored  by  vascular 
turgeseence. 


COURSE,  DURATION,  TERMINATION,  AND  PROGNOSIS.         221 

patients,  especially  as  regards  tuberciilosis,  and  in  the  more  un- 
favorable prognosis  wliicli  complicaliiig  diseases  have  in  the  insane; 
partly,  also,  this  is  due  to  the  nutritive  disturbance  of  the  brain 
which  readily  leads  to  organic  changes  (acute  delirium,  etc.)  or  cere- 
bral inanition  and  coinpiieations  (cerebral  edema,  C(;nvulsions).  Ac- 
count must  also  be  taken  of  the  fact  that  psychoses  often  lead  to 
self-injuries  and  refusal  of  food  as  result  of  emotional  states,  and 
that  sleeplessness  leads  to  exhaustion.  The  prognosis  as  to  life,  is 
directly  dependent:  (a)  Upon  the  nature  of  the  disease.  Idiopathic 
affections,  dementia  paralytica,  and  related  processes  almost  always 
end  fatally,  (h)  Upon  age.  Fatal  exliaustion  readily  occurs  in  ad- 
vanced years,  (c)  Upon  the  stage  and  course  of  the  disease.  The 
more  violent  the  course  and  the  earlier  the  period  of  the  disease,  the 
greater  is  the  percentage  of  fatal  cases. 

According  to  Behier,  of  17,107  insane,  12  per  cent,  died  in  the  first  month 
of  tlie  disease,  7  per  cent,  in  the  second,  and  0  per  cent,  in  the  third. 

In  the  hxter  stages  of  insanity  the  mortality  diminishes  considerably,  but 
it  remains  five  times  greater  tlian  that  of  healthy  individuals  of  like  age 
(Hagen). 

In  individual  eases  the  subsidence  of  excitement  with  the  continuance  of 
the  disease,  and  the  regular  and  purely  vegetative  life  of  an  asylum,  may,  on 
the  contrary,  have  the  effect  to  prolong  life;  thus  there  are  certain  cases  in 
asylums  that  have  attained  the  age  of  eighty  or  ninety,  having  passed  from 
fifty  to  sixty  years  there. 

3.    PKOG>rOSIS   OF   CUEE. 

The  prognosis  as  to  restoration  is  especially  difficult.  There  is 
no  single  certain  criterion  of  incurability.  The  histor}^,  etiology,  and 
pathogenesis,  the  course,  and  the  frequency  of  certain  symptoms  are 
the  points  upon  Avhich  it  must  rest  in  the  concrete  case.'- 

In  general,  insanity  must  be  regarded,  when  treatment  is  begun 
at  the  right  time,  as  a  curable  disease. 

In  the  best  institutions  the  percentage  of  recoveries  varies 
between  20  and  60  per  cent.  This  variation  is  dependent  on  the 
frequency  of  degenerate  conditions  in  the  population;  on  the  degree 
of  knowledge  of  physicians  which  enables  them  to  recognize  and 
treat  the  disease  early;  and  finally  on  the  enlightenment  of  the 
public  upon  which  recognition  of  the  value  of  admission  to  an  insti- 
tiition  for  the  insane  depends. 


^Schule  ("Handbook,"  page  365)  regards  the  process  in  psychoses  as  an 
aft'ection  of  the  psychic  centers,  which  is  in  general  connected  with  hereditary 
taint,  the  physiologic  evolutionary  periods  of  life,  but  especially  with  the  in- 
dividual development  and  the  intensity  of  the  form  of  disease  in  the  single 
case. 


ooo         GENERAL  rATllOLOC.Y  AND  THERAPY  OF  INSANITY. 

In  general,  ocrtain  points  for  prognosis  are  obtained  from  the 
duration  and  course,  and  from  single  sj'mploius  and  causal  conditions 
found  in  the  individual  case. 

(a)  DuRATiox. — With  reference  to  this  point,  the  statement 
that  the  longer  the  duration  the  more  unfavorable  the  prognosis  is 
unquestioned.  Curability  stands  practically  in  inverse  proportional 
relation  to  the  duration  of  the  disease.  The  greatest  number  of 
recoveries  (up  to  GO  per  cent.)  take  phuc  dui-ing  the  early  months  of 
the  disease.  In  the  second  six  months  only  about  25  per  cent, 
recover,  while  in  the  course  of  the  second  year  recoveries  reach  only 
from  2  to  5  per  cent ;  nevertheless  there  is  no  absolute  limit  in  time 
of  curability.  There  are,  indeed,  rare  cases  due  to  profound  acci- 
dental physical  diseases  (typhoid,  cholera,  malaria),  or  to  a  fall  or 
blow  on  the  head,  which  have  recovered  after  insanity  had  lasted 
many  years.  Too,  during  the  climacteric  sexual  psychoses  that  have 
lasted  for  years  may  disappear. 

The  foregoing  rule  is  influenced,  finally,  by  external  circum- 
stances. If  these  be  unfavorable,  then  after  very  short  duration  a 
case  may  become  incurable  which,  under  favorable  circumstances  like 
those  usually  found  only  in  asylums  for  the  insane,  would  have  had 
much  greater  chance  of  recovery. 

(b)  Course. — The  sudden  outbreak  of  a  psychosis  allows  a  more 
favorable  prognosis  in  general  than  slow  development  under  the 
constant  influence  of  injurious  conditions.  In  the  first  case  the 
course  is  stormier,  more  acute,  and  does  not  permit  persistence  and 
psychic  valuation  of  isolated  symptoms;  in  the  second  case  there  is 
a  gradual  abnormal  transformation  of  the  whole  personalit}'-,  with 
fatal  tendency  to  systematization  of  the  developing  delusions.  At 
least  in  such  a  case  a  chronic  course  is  to  be  expected  with  certainty. 

"With  the  subsidence  of  a  chronic  psychosis  the  rule  is  quite  the 
contrary.  In  such  a  case  sudden  recovery  is  merely,  as  a  rule,  an 
intermission  which  will  be  soon  followed  by  a  recurrence  of  the  dis- 
ease; gradual  lysis,  with  more  and  more  marked  remission,  is  the 
termination  to  be  desired.  In  the  details  of  its  course  the  more  a 
disease-picture  presents  the  character  of  a  curable,  benign  psychos's 
(psychoneurosis),  the  better  is  the  prognosis.  Progressive  evolution 
of  groups  of  symptoms  which  become  more  and  more  severe — such 
as  those  characteristic  of  insanity  developed  out  of  the  neuroses, 
primary  occurrence  of  systematized  delusions,  a  protean  or  marked 
periodic  course  in  the  recurrence  of  the  series,  and  distinctly  marked 
attacks — points  to  psychic  degeneration  and  is,  in  general,  of  bad 
pmen.    A  certain  variability  of  symptoms,  if  it  be  not  protean  ov 


COURSE,  DURATION,  TER:\r  I  NATION,  AND  PROGNOSIS.         223 

periodic,  permits  a  more  favorable  prognosis  than  persistent  symp- 
toms, especially  hallucinations  and  delusions  with  elaboration  into 
a  systematized  delusional  state. 

(cj  Etiology. — With  reference  to  prognosis,  it  is  of  the  great- 
est importance  wliether  the  f)sychosis  depend  upon  an  unfavorable 
accidental  causal  moment  or  whether  it  depend  uj)on  a  taint  of  the 
whole  constitution  of  hereditary  or  other  origin. 

If  insanity  arise  out  of  such  a  taint;  if  it  stand  in  pathogenic 
relation  with  an  originally  abnormal  development  and  formation  of 
character;  if  it  be  only  or  merely  a  pathologic  intensification  of 
anomalies  of  character;  if  it  present  a  progressive  development  of 
psychopathic  symptoms,  which  at  first  Avere  but  neurotic  and  ele- 
mentary, to  more  severe  conditions,  then  the  prognosis  is  especially 
bad,  and  the  more  so  if  the  outbreak  were  not  sudden,  but  simply 
the  unnoticed  development  of  taint  and  abnormal  mental  peculiarity. 

The  question  of  heredity,  which  often  is  too  much  generalized  in 
prognosis,  must  be  regarded  from  this  standpoint.^ 

If  the  hereditary  factor  is  limited  to  a  simple  disposition,  which 
before  the  outbreak  of  the  disease  did  not  manifest  itself  clinically 
by  neurotic  or  psychic  anomalies, — in  other  words,  if  the  brain  be 
simply  a  locus  minoris  without  other  signs  of  disturbance  of  devel- 
opment or  functional  degeneration, — then  the  prognosis  is  really 
more  favorable  than  in  non-hereditary  cases.  In  the  cases  under 
consideration  accessory  injurious  influences,  it  is  true,  induce  dis- 
ease, but  they  are  without  prof  ound  injurious  influence  on  the  psychic 
organ,  the  functions  of  which  are  wanting  in  stability,  and  after  the 
subsidence  of  the  disturbance  it  easily  regains  its  usual  equilibrium. 
On  the  other  hand,  wdien  accidental  causes  induce  mental  disturb- 
ance in  a  burdened  individual,  the  effect  is  much  more  profound,  and 
therefore  much  more  difficult  to  overcome. 

It  is  quite  a  different  matter  in  cases  in  which  the  hereditary 
factor  is  revealed  in  original  defect  of  character,  eccentricities,  and 
disproportionate  development  of  psychic  energies,  and  especially  by 
symptoms  due  to  a  taint  in  which  the  disease  forms  the  last  link 


^  Jung  found  in  hereditary  cases  45.5  per  cent,  of  recoveries  in  males  and 
46.9  per  cent,  of  recoveries  in  females,  compared  with  38.37  per  cent,  of  recov- 
eries in  males  and  38.5  per  cent,  in  females  without  hereditai-y  antecedents. 

With  careful  division  of  hereditary  cases  into  predisposed,  tainted,  and 
congenital,  I  found  in  the  first  category  58.4  per  cent,  of  recoveries  in  males 
and  57.7  per  cent,  recoveries  in  females.  In  the  second  category  16.1  per  cent, 
in  males  and  13.2  per  cent,  in  females;  in  the  last  category  no  recovery  in 
either  sex. 


224  GENERAL  PATHOLOGY  AND  THEKAPV  OF  INSANITY. 

in  a  chain  of  pj^yehopatliir  anomalies  and  symptoms  of  development. 
The  prognosis  in  siieh  cases  is  had,  and  in  congenital  mental  disease 
(original  paranoia,  moral  insanity)  it  is  actually  hopeless,  if  the 
taint  manifest'  itself  in  a  state  of  congenital  mental  weakness,  and, 
if  a  psychosis  develop  in  siuh  an  imheeilc,  tlu'n  the  prognosis  with 
reference  to  the  restoration  of  the  sUilits  (jtio  aiilc  is  much  more  nn- 
favorahle  than  in  the  case  of  normal  individuals.  With  reference  to 
gravity  of  prognosis  psychoses  dependent  upon  taint  follow  directly 
after  ue(|uired  idiopathic  mental  disturhances.  Insanity  due  to  head 
injuries,  insolation,  a])ople.\y,  meningitis,  etc.,  have,  for  the  most  part, 
an  unfavorahlo  prognosis.  In  this  class  of  cases  cerel)ial  lues  is  more 
favorahk'.  Still,  in  the  majority  of  such  cases,  recoveiy  willi  defect 
is  the  result. 

The  prognosis  of  sympathetic  nu'nial  (listui'ha)U'C  depends  essen- 
tially npon  whether  the  sympathetic  cause  is  one  which  can  be 
removed. 

The  most  favorahle  psychoses  are  those  due  to  anemia,  menstrual 
disturbance,  and  curable  atfections  of  the  digestive  tract  and  genitals. 
Psychoses  due  to  heart  disease  and  pulmonary  tuberculosis  have 
rather  a  bad  prognosis. 

The  prognosis  of  postfebrile  insanity  varies  according  to  whether 
it  be  due  to  grave  cerebral  complications  or  the  expression  of  anemia 
and  states  of  exhaustion. 

Alcoholic  insanity  permits  a  favorable  prognosis  with  reference 
to  the  single  attack;  recurrence  is  naturally  very  common.  The 
chronic  insanity  of  drinkers  is  dependent  npon  grave  idiopathic  dis- 
turbance of  the  brain,  and  at  best  can  end  only  in  recovery  with 
defect.  In  insanity  due  to  sexual  exhaustion  and  onanism  recovery 
is  to  be  expected  only  in  the  initial  stages,  when  the  mental  disturl)- 
ance  is  emotional.  Insanity  of  pregnancy,  of  the  pucrperium,  and  of 
lactation  usually  ends  in  recovery.^ 

An  outbreak  of  mental  disease  in  youth  is  much  more  favorable 
than  one  occurring  in  very  advanced  years.  Often  in  the  latter  case 
the  decision  depends  upon  the  presence  of  signs  of  senile  involution 
of  the  brain. 


^Schmidt  found  in  liis  cxporioncG  tlio  ])orfciitntjo  of  iTcovcrics  (o  ho  30.2 
per  cent.;  Holm,  40  per  cent.;  Kipping,  42.8  per  cent.;  Liihlx-n,  ();?.4  jicr  cent.; 
Reid,  7L5  per  cent.;    Macdonald,  81  per  cent. 

Schmidt's  cases  of  insanity  of  pregnancy  gave  35.3  per  cent,  of  recoveries, 
those  of  the  pnerperium,  39.3  per  cent.,  and  those  of  lactation.  .^IJ.  Under  all 
circumstances  mania  is  more  favorable  than  melancholia.  These  figures  apply 
only  to  severe  cases  treated  in  asylums. 


COURSE,  DTIHATION,  TERMINATION,  AND  PROCNORIS.         225 

The  psychoses  of  chilrllioocl,  on  account  of  the  hereditary  taint 
or  the  organic  causes  so  common  in  such  cases,  have  rather  an  un- 
favorahle  prognosis,  and  hesides  they  endanger  the  further  develop- 
ment of  the  mind.  Psychoses  arising  during  the  physiologic  periods 
of  puberty  and  the  climacteric  allow  a  favorahie  prognosis  only  when 
they  are  based  upon  simple  predisposition  and  not  npon  a  taint. 
Insanity  based  upon  an  hysteric  or  other  neurotic  foundation  is  only 
favorable  when  it  presents  an  intercurrent  and  emotional  character. 
If  it  be  merely  a  developmental  stage  in  the  course  of  a  neuropsycho- 
sis, then  it  is  of  bad  omen. 

A  prognosis  cannot  be  based  upon  the  somatic  or  psychic  cause 
that  induced  the  disease.  "Whether  a  psychic  cause  produced  its 
effects  suddenly  or  gradually  is  a  circumstance  of  more  importance. 
A  transitory,  but  violently  effective,  cause  permits  a  much  more  fa- 
vorable prognosis  than  a  psychic  cause  that  has  been  acting  for  years 
and  gradually  undermining  the  physical  and  mental  constitution. 

Continued  trouble,  unfulfilled  desires  and  efforts,  and  strong 
passions  are  special  causes  which  slowly,  but  surely,  destroy  the 
mental  life.  If,  in  addition,  there  be  material  misery,  drunkenness, 
and  other  vices,  then  recovery  is  scarcely  to  be  expected. 

Insanity  due  to  psychic  contagion,  when  separation  from  the 
infecting  surroundings  is  carried  out  early,  permits  a  favorable 
prognosis. 

(d)  AccoEDiNG  TO  Single  Si'mptoms. — 1.  Psychic  Symptoms. — 
Profound  clouding  of  consciousness,  if  it  come  on  gradually  during 
the  course  of  the  disease,  indicates  a  grave  form,  but  sudden  and  pri- 
mary occurrence  of  disturbance  of  consciousness  is  more  favorable. 

Profound  mental  incoherence,  when  it  is  not  simultaneous  with 
the  height  of  a  psychosis,  is  unfavorable ;  if  it  still  continue  after  the 
subsidence  of  the  acute  stage  and  after  the  disappearance  of  the 
emotional  excitement,  then  it  usually  indicates  the  beginning  of  sec- 
ondary dementia.  Weakness  of  memory,  especially  if  it  be  partial 
and  particularly  for  recent  events,  indicates  a  grave  idiopathic  disease. 

Perversion  of  feeling  and  thought,  evil  inclinations,  and  eccen- 
tricities, occurring  in  the  course  of  a  subsiding  psychosis,  point  to 
the  development  of  dementia,  while,  on  the  other  hand,  return  of 
former  inclinations,  habits,  ethic  feelings,  and  moral  judgment  points 
to  an  early  disappearance  of  the  disease. 

Loss  of  sense  of  modesty  and  uncleanliness,  if  they  do  not 
accompany  the  height  of  mania,  indicate  mental  decay. 

Coprophagy  and  the  eating  of  disgusting  things  in  general  occur 
only  with  profound  disturbance  of  consciousness. 


226  GENERAL  PATIlOLiXJY   AM)  TllKlJATY  OF  INSANITY. 

,  Insensibility  to  heat,  cold,  and  bright  sunlight,  and  absence  of 
the  feeling  of  satisfaction  in  eating,  are  bad  signs,  like  anesthesias. 

Sexual  excitement  in  j'oung  persons  is  not  ominous,  but  when 
it  occurs  in  advanced  years  it  is  of  evil  omen. 

The  formation  of  ]iew  words  occurs  almost  exclusively  in  in- 
curable forms  of  insanity.  Aphasia  points  to  idiopathic  organic 
disease. 

Imperative  and  impulsive  acts  are  ordinarily  manifestations  of 
degenerate  psychoses. 

The  impulse  to  collect  objects  of  all  kinds  is  of  evil  omen  when 
it  is  not  a  prodrome  or  symptom  of  mania. 

Delusions  are  unfavorable  symptoms  when  they  are  primary  and 
devoid  of  emotional  foundation  or  have  a  primordial  character  and 
do  not  change. 

When  they  are  desultory  and  arise  as  a  kind  of  allegoric  explana- 
tion, and  are  symptoms  superadded  to  emotional  states,  they  are  not 
in  themselves  unfavorable.  Grand  delusions  are  of  graver  prognosis 
than  depressive  delusions,  and  of  the  latter  those  due  to  diminished 
self -feeling  are  more  favorable  than  delusions  of  persecution. 

Imperative  ideas  occur  exclusively  in  tainted  individuals. 

Hallucinations  and  illusions  are  of  bad  omen  when  they  are 
stationary  and  affect  several  senses. 

Illusions  are  less  serious  than  hallucinations;  of  the  latter, 
auditory,  gustatory,  and  olfactory  are  more  unfavorable  than  those 
of  the  sense  of  sight. 

2.  Physical  Symptoms. — Motor  disturbances  of  all  kinds  have  an 
important  and  usually  bad  prognostic  significance,  for  they  indicate 
grave  idiopathic  diseases.  This  is  especially  true  of  convulsions,  paral- 
ysis, and  disturbances  of  co-ordination  when  the}^  are  not  hysteric. 

The  disturbances  of  so-called  tetany  and  catalepsy  are  less  un- 
favorable. 

Tremor  may  be  due  to  alcoholism,  anemia,  or  nervous  excite- 
ment, and  therefore  has  not  the  same  ominous  significance  as  other 
motor  disturbances. 

Inequality  of  the  pupils  and  strabismus  may  be  accidental  or 
habitual,  and  they  are  to  be  considered  only  in  connection  with  other 
s}Tnptoms.  Disturbance  of  speech  (stumbling  over  syllables)  was  re- 
garded by  Esquirol  as  a  sign  of  fatal  termination.  It  always  indi- 
cates grave  idiopathic  disease  (paralysis) ;  and  grinding  the  teeth  has 
the  same  significance. 

Expression,  appearance,  and  attitude  are  very  important  in  prog- 
nosis.   Muscular  relaxation,  with  the  chin  fallijig  on  the  chest,  indl- 


COURSE,  DUUATrON,  TEllMlNATJON,  AK\)  1M;0(JN0.SIR.         227 

cates  usually  a  transition  to  dementia;  and  the  same  is  true  of 
relaxation  of  the  sphincters,  and  dribbling  of  saliva  when  its  secre- 
tion is  not  increased. 

From  a  prognostic  point  of  view,  changes  in  the  innervation  of 
the  muscles  of  facial  expression  are  especially  valuable.  In  cases 
where  the  insanity  will  have  an  unfavorable  termination,  this  is 
often  shown  early  by  the  empt}^,  fixed,  expressionless  glance,  and  the 
peculiarly  distorted  features,  dependent  upon  unequal  innervation 
and  contractions. 

Sleeplessness  and  refusal  of  food,  if  they  are  more  than  transi- 
tory, are  of  evil  omen,  as  are  also  trophic  disturbances  (decubitus, 
othematoma,  etc.).  This  is  also  true  of  subnormal  or  elevated  tem- 
perature of  neurotic  origin. 

The  return  of  the  menses  has  a  critical  significance  only  when 
the  mental  disturbance  has  arisen  in  connection  with  their  suppres- 
sion; otherwise  their  return  indicates  only  an  improvement  of  the 
general  health  and  is  favorable  in  just  that  sense;  but  in  many 
cases  it  is  without  significance. 

Finally,  in  connection  with  mental  indications  the  most  impor- 
tant prognostic  sign  is  the  weight  or  rather  the  state  of  nutrition  of 
the  patient.  Nasse  did  a  great  service  in  establishing  its  prognostic 
value. 

Increase  of  weight  which  accompanies  or  precedes  mental  im- 
provement, especially  if  it  be  rapid,  according  to  jSTasse's  inves- 
tigations is  a  sure  sign  of  convalescence.  A  slight  diminution  of 
body-weight  after  it  has  attained  a  maximum  predicates  recovery. 

When  mental  improvement  takes  place  without  or  with  only 
slight  increase  of  body-weight,  the  cure  is  doubtful  and  a  relapse  is 
to  be  expected. 

If  body-weight  increase  with  no  mental  improvement,  then 
transition  to  a  state  of  incurable  mental  weakness  is  indicated. 

As  long  as  a  psychosis  remains  at  its  height,  it  is  always  accom- 
panied by  loss  of  body-weight.  If  this  loss  of  Aveight  be  great  and 
rapid  in  spite  of  sufficient  nourishment,  it  indicates  a  grave  progress- 
ive disease  of  the  brain  or  a  complication  of  the  psychosis  with  a 
grave  general  disease  like  tuberculosis. 

3.    PkOGNOSIS  of  EECüREEISrCE. 

With  reference  to  the  prognosis  of  recurrence,  in  the  first  place 
it  must  be  considered  that  statistics  show  that,  of  100  recoveries  in 
patients  discharged  from  asylums,  about  25  per  cent,  have  a  recur- 
rence.   In  the  individual  case  everything  depends  upon  the  biologico- 


228  CFAFnAF;  P.\T11(^I.0(!Y  AND  '111  i:i;.\  F^V  OF  TXSAMTV. 

etiologic  I'xtonial  cirounistaiicos:  for  o.\:uti]il(\  an  accidental  rase  of 
insanity  occurring  after  typhoid  fever  wiiliout  predisposition  will 
scarcely  be  repeated,  Avhilc  a  case  of  insanity  foiiiidod  on  taint,  espe- 
cially if  it  l)e  hereditary,  runs  the  danger  of  hoing  repcati-d  as  a 
result  of  aeeessory  injurious  inlluences  of  all  kinds — indeed,  even  as 
a  result  of  physiologic  changes  at  the  critical  periods  of  life. 

Too,  bad  social  relations,  unkind  trcatnu-nt  of  patients  dis- 
charged from  the  asylum,  financial  difficulties  due  to  disease  and 
absence,  too  early  discharge  from  the  asylum,  and  return  to  evil 
habits  (drink,  etc.)  are  often  responsible  for  recurrence.  The  pre- 
vention of  recurrence  by  marriage  in  the  case  of  recovered  female 
patients,  which  was  found  by  Dick  to  bo  efl'cctual,  is  contested  by 
other  observers. 

4.  Prognosis  of  HEREorrARY  Traxsmissiox. 

Prognosis  of  hereditary  transmission  is  an  especially  delicate 
question  which  can  only  be  answered  in  a  concrete  case,  and  then 
only  with  probability. 

The  important  point  for  the  decision  of  the  question  lies,  of 
course,  in  the  pathogenesis  of  the  psychosis  the  hereditary  influence 
of  which  is  to  be  feared. 

If  the  psychosis  be  constitutional  and  present  degenerate  foun- 
dation and  features,  then  there  is  great  danger  of  transmission;  if, 
on  the  other  hand,  it  has  been  accidentally  acquired  without  any 
predisposition  and  has  been  cured,  and  also  if  its  symptoms  have 
been  benign  and  followed  by  recovery  without  defect,  then  there  is 
no  probability  of  hereditary  influence  upon  descendants.  This  influ- 
ence, however,  is  possible  if  conception  take  place  during  the  course 
of  the  psychosis. 

With  reference  to  the  possibility  or  probability  of  hereditary 
influence  upon  descendants  in  cases  where  there  has  been  taint  or 
mental  disease  in  ancestors,  the  following  should  be  considered:  The 
worst  case  is  where  the  father  and  mother  are  both  tainted  and 
mentally  burdened  before  the  conception  of  the  descendants  under 
consideration;  and,  too,  if  the  mental  disturbance  itself  presented 
a  degenerate  character.  In  such  a  case  as  this  mental  disease  in 
some  form  or  other  in  the  descendants  is  to  be  expected  almost  with 
certainty.  However,  the  law  of  atavism  might  save  the  individuals 
if  earlier  ancestors  were  healthy. 

If  only  the  father  or  the  mother  is  tainted  or  diseased,  then  tlie 
question  depends  essentially  upon  which  parent  the  indi\idual  phys- 
ically resembles. 


COURSE,  DURATION,  TERMINATION,  AND  PROGNOSIS.         229 

Eicharz  has  gone  into  the  question  more  deeply  in  an  anthropolop^ic 
sense.  lie  starts  out  with  the  fact  that  sex  is  not  a  transmissibh;  peculiarity 
of  parents,  but  in  great  degree  a  foiin  of  existence  based  upon  tlie  degree  of 
organization  of  the  descendant,  in  which  the  male  represents  the  higher  de- 
gree. The  center  of  gravity  of  the  procreative  process  lies  in  the  maternal 
organism.  The  influence  of  the  male  element  lies  merely  in  the  excitation  of 
the  developmental  movement  wliich  is  imminent  in  the  germ,  with  also  par- 
ticipation in  the  qualifying  peculiarities  of  the  male  element,  to  which,  how- 
ever, sex  in  nowise  belongs.  The  greater  the  maternal  generative  power,  the 
surer  will  the  offspring  be  a  male;  and,  at  the  same  time,  the  smaller  the 
qualifying  paternal  influence,  the  surer  will  he  resemble  the  mother.  This 
resemblance  is  found  less  in  features  and  bodily  form  than  in  the  more  im- 
portant points  of  the  color  of  the  skin,  the  hair,  and  the  iris  (Huxley, 
Virehow) :  characteristics  which  are  of  much  more  importance  with  reference 
to  differences  of  race.  Crossed  inheritance  of  these  physical  peculiarities  (son 
to  mother,  daughter  to  father)  seems  to  be  the  most  favorable.  Uncrossed 
sexual  inheritance  is  slightly  degenerate.  When  a  descendant  resembles 
neither  parent,  Richarz,  in  accord  with  Morel  ("De  I'Heredite  Morbide  Progres- 
sive"), finds  that  the  condition  is  decidedly  degenerate,  and  that  it  is  often 
the  only  explanation  for  insanity  in  a  family  that  had  previously  been  intact. 

All  observers  (Esquirol,  Baillarger,  Jung,  and  others)  agree 
that  insanity  in  the  mother  ^  is  more  dangerous  to  descendants  than 
insanity  in  the  father.  This  is  in  accordance  with  the  natural  law 
and  the  fact  that  holds  for  animals :  that  the  female  sex,  which  pre- 
dominates, more  readily  transmits  to  descendants  than  does  the  male 
sex.  For  the  same  reason,  as  Eicharz  makes  plausible,  a  daughter, 
representing  the  inferior  sex,  more  readily  inherits  the  disease  of 
her  parents  than  does  a  son ;  and  it  is  therefore  natural  that  statis- 
tically hereditary  insanity  is  6  per  cent,  more  frequent  in  women  than 
in  men  (Jung). 

Jung  has  emphasized  the  great  importance  of  physical  resem- 
blance in  reference  to  the  question  of  inheritance,  and  he  formulated 
the  following  rule:  "If  a  descendant  inherit  the  physical  halntfts 
of  his  tainted  ancestors,  then  he  also  inherits  their  mental  constitu- 
tion; and,  if  his  ancestors  become  insane,  then  there  is  a  great 
probability  that  the  descendant  at  about  the  same  age  and  under  the 
influence  of  similar  exciting  causes  will  have  an  attack  of  insanity.^' 

Richarz  gives  the  following  table  of  probability  of  inheritance  of  mental 
disease  based  upon  his  conclusions:  — 

1.  Daughter  who  resembles  the  mother. 

2.  Son  who  resembles  the  motlier. 
J.  Mother  tainted  ^    3    g^^  ^^^^^  resembles  the  father. 

4.  Daughter  who  resembles  the  father. 


^  Jung  (Allgemeiner  Zeit,  für  Psychiatrie)  finds  that  insanity  is  at  least 
one-third  more  frequently  inherited  from  the  mother  than  from  the  father. 


^30         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 


IT.  Father  tainted   ■< 


Endangers  1.  Son  Avho  resembles  the  father. 

2.  Daughter  Avho  i-esembles  the  father. 

3.  Daughter  who  resembles  the  mother. 

4.  Son  who  resembles  the  mother. 


According  to  this,  a  daughter  who  resembles  au  insane  mother  is  the 
most  predisposed,  ami  a  son  who  resembles  his  mother,  but  has  an  insaTie 
father,  is  least  disposed.  Complete  lack  of  resemblance  as  to  the  physical 
types  of  the  parents  is  a  sign  of  degeneration. 

The  profound  significance  of  these  prognostic  points  with  refer- 
ence to  the  degeneration  of  individuals,  as  well  as  of  nations,  is 
worthy  of  recognition  and  consideration.  Persons  neurotic  by  hered- 
ity, as  well  as  those  predisposed  to  tuberculosis,  should  abstain  from 
procreation.  Unfortunately,  it  is  especially  in  sucli  individuals  that 
intensified  sexual  impulse  is  observed,  and  this  is  responsible  for  tlie 
fact  that  the  two  curses  of  humanity — insanity,  which  destroys  one 
in  three  hundred;  and  tuberculosis,  which  destroys  one  in  three 
hundred  and  twenty,  of  the  meml)ers  of  society — increase  rather  than 
diminish,  in  spite  of  all  scientific  teaching. 


PART    FOURTH. 
General    Diagnosis. 


CHAPTER  I. 
Diagnosis  of  the  Disease. 

The  general  question  whether  a  person  be  mentally  sound  or 
unsound  may  be  demanded  of  the  physician  in  court  or  at  the  bedside. 

In  court  this  question  is  asked  when  there  is  doubt  whether  mental 
peculiarities  observed  are  merely  the  expression  of  emotion,  of  passionate 
excitement,  of  voluntary  self-abandonment  to  immoral  inclinations  and  im- 
pulses, of  voluntary  deception,  or  the  natural  result  of  an  underlying  disease 
of  the  brain. 

The  jurist  requires  a  decision  on  this  point  in  order  to  be  able  to  decide 
whether  the  individual  should  be  punished  for  any  illegal  act,  declared  in- 
capable of  exercising  civil  liberty,  or  whether  it  be  necessary  to  deprive  him  of 
personal  liberty  by  committing  him  to  an  asylum. 

At  the  bedside  the  question  arises  whether  the  psychopathic 
symptoms  present  exist  in  and  for  themselves — that  is  to  say,  are  the 
expression  of  some  brain  disease  which  clinically  and  traditionally  is 
called  insanity — or  whether  they  are  merely  symptomatic  and  a  part 
of  the  manifestations  of  a  general  disease  (deliriiim  of  fever,  inani- 
tion) or  of  an  intoxication  or  some  other  cerebral  or  nervous  disease. 

Notwithstanding  the  fact  that  the  general  diagnosis  of  whether  an  indi- 
vidual be  insane  or  not  is  so  easy  and  sure  that  it  can  be  made  in  many  cases 
even  by  the  public,  there  are  other  cases  Avhich  demand  all  the  science  and 
skill  of  the  most  experienced  observers,  and  in  which  the  question  cannot  be 
decided  immediately  and  with  certainty.  In  the  first  place,  the  reason  for  this 
lies  in  the  fact  that  in  insanity  there  are  no  specific  symptoms;  that  those 
which  occur  are  equivocal  and  permit  a  just  conclusion  only  when  they  are 
considered  and  interpreted  together. 

Even  in  the  domain  of  physical  disease,  where  exact  physical  means  for 
diagnosis  are  at  hand,  it  is  often  difficult  to  decide  where  health  changes  to 
disease.     How  much  more  difficult  must  it  be,  then,  in  the  psychic  domain, 

(231) 


233  GENERAL  PATHOLOGY  AND  TTTERAPY  OF  INSANITY. 

where  a  standard  of  mental  health  ean  only  be  thonght  of  as  ideal;  where  no 
inilividual  is  exaetly  like  another,  and  emotions,  passions,  and  variations  of 
feeling,  of  thought,  and  of  will  from  tlie  majority  of  mankind,  evi-n  errors 
of  the  understanding  and  illusions  of  the  senses,  are  possible  witliin  tlie  limits 
of  physiologic  life,  and  as  elementary  mental  di-l  uriiamos,  are  absdlulcly  com- 
jiatible  Avith  the  existenee  of  mental  clearness  and  free  will. 

The  dillienltics  which  arise  out  of  the  nature  of  the  subject  are  furtlier 
increased  by  the  fact  that  the  development  of  the  mental  disturbance  in 
question,  as  well  as  the  previous  life-history  of  the  case,  remain  unknown;  or 
tlie  disturbance  has  developed  unnoticed  out  of  habitual  anomalies  of  char- 
acter, pa.ssions,  or  vicious  and  innnoral  lite;  by  the  suspicion  of  intentional 
deception  or  concealment  of  symptoms  on  the  part  ui  the  patient :  and,  linally, 
by  the  fact  that  the  ])eriod  of  observation  is  too  short,  and  thus  symptoms 
of  a  disease  which  is  distinctly  periodic  or  not  yet  fully  developed  may  escape 
observation. 

The  i'ol lowing  may  be  given  as  general  rules  for  psychiatric 
diagnosis : — 

1.  Mental  diseases  are  cerebral  affections  with  predominating, 
but  not  exclusive,  psychic  symptoms.  Even  though  the  latter  are 
essential  for  a  judgment  of  the  mental  condition,  still  the  diagnosis 
must  not  depend  upon  them.  Other  possible  signs  of  existing  cere- 
bral and  nervous  disease  must  be  investigated;  the  psychologic  diag- 
nosis must  be  deepened  and  broadened  into  a  neuropathologic 
diagnosis.  It  may  even  be  advisable  to  put  aside  at  first  the  equivocal 
mental  symptoms  and  consider  the  general  question  of  the  existence 
of  a  congenital  or  acquired  cerebral  or  nervous  disease.  If,  along 
with  anatomic  and  functional  signs  of  degeneration,  or  of  vasomotor 
and  functional  sensory  disturbances  which  can  be  referred  to  a  cen- 
tral cause,  there  be  mental  symptoms  of  equivocal  significance  (irri- 
tability, abnormal  emotions,  perverse  acts,  immoral  inclinations,  and 
the  like),  then  a  proper  light  is  thrown  on  their  significance,  and  the 
presumption  that  they  are  abnormal  (chronic  alcoholism;  degenera- 
tive, moral,  epileptic  insanity,  and  the  like)  becomes  almost  a  cer- 
tainty. 

2.  ]\Iental  diseases,  as  Schule  emphasized,  are  not  only  diseases 
of  the  brain,  but  at  the  same  time  diseases  of  the  personality.  The 
whole  earlier  personality,  especially  its  origin,  must  be  considered, 
and  the  psychologic  diagnosis  must  be  enlarged  to  an  anthropologic 
diagnosis. 

The  important  point  for  the  general,  as  well  as  the  special,  diag- 
nosis of  insanity  lies  unquestionably  in  the  history.  The  general 
individuality,  with  its  development,  and  the  former  habitual  manner 
of  feeling  and  reaction,  are  its  next  subjects  of  investigation,  and  in 
particular  the  mental  constitution,  either  inherited  or  congenital. 


GENERAL  DTAflNOSLS.  2'i3 

Inherited  tenclenc_y,  education,  and  cirraiinstariccs  of  life  are  the 
factors  out  of  which  individuality  arises.  The  importance  o£  the 
first  in  forming  a  judgment  as  to  whether  mental  peculiarities  are 
abnormal  or  normal  is  not  sligJit. 

3.  Mental  diseases  are  actual  diseases.  They  are  accompanied 
by  disturbance  of  the  vegötative  life.  Most  careful  pliysical  examina- 
tion must  go  hand  in  band  with  mental  examination.  It  is  often  only 
by  means  of  the  former  that  we  are  able  to  determine  whether  we 
have  to  do  with  an  independent  psychosis  or  a  symptomatic  disturb- 
ance of  the  psychic  functions. 

Specially  important  physical  symptoms  are  disturbance  of  sleep, 
of  nutrition,  of  the  functions  of  digestion,  and  of  the  intestines,  as 
well  as  of  the  secretions.  These,  however,  have  a  positive  value  only 
in  the  initial  stages  of  insanity.  In  the  final  stages  they  may  have 
quite  disappeared,  and  their  absence  has  no  significance. 

4.  As  a  disease,  insanity  has  causes.  Mental  disease  in  itself  is 
an  unusual  phenomenon.  It  must  have  an  efficient  cause,  whether 
that  be  in  the  powerful  influence  of  predisposition  or  in  tlie  special 
intensity  or  cumulation  of  accidental  causes.  The  psychologic  inves- 
tigation must  be  widened  to  include  the  etiologic  and  pathogenic 
factors.  The  earlier  and  more  clearly  pathogenically  the  symptoms 
of  mental  change  follow  a  given  cause,  the  greater  is  their  sig- 
nificance. 

The  value  of  the  etiologic  features  of  a  given  case  are  diminished  only 
apparently  by  the  fact  that  sometimes  no  cause  can  be  discovered,  and  that  a 
preceding  depressing  cause  makes  it  doubtful  whether  the  following  mental 
change  be  a  physiologic  reaction  to  the  cause  or  a  pathologic  phenomenon. 

When  no  exciting  cause  can  be  found,  there  is  always  congenital  or  ac- 
quired predisposition  or  even  congenital  disease. 

It  is  precisely  in  such  cases  that  the  history  gives  light  by  an  investiga- 
tion of  the  anthropologic  and  etiologic  factors,  since  frequently  this  shows 
that  the  eqtiivocal  disease-picture  is  the  acme  of  development  of  a  defective 
and  abnormally  predisposed  personality  which  began  in  childhood.  In  the  sec- 
ond case  the  question  is  more  difficult,  when  the  mental  depression  observed 
may  be  regarded  as  the  natural  reaction  to  a  depressing  cause. 

The  painful  emotional  state  occurring  in  healthy  individuals  within 
physiologic  limits,  and  the  commencement  of  abnormal  depression,  may  have 
like  characteristics. 

In  such  a  case,  before  all  other  considerations,  the  course  of  the  disease, 
exact  knowledge  of  the  usual  manner  of  reaction  of  the  individual,  and  minute 
consideration  of  the  symptoms  in  detail  are  the  decisive  points. 

If  the  exciting  cause  be  slight;  if  the  effect  in  the  individual  be  unusu- 
ally intense  and  prolonged;  if  the  depression  increase  with  time;  if  it  con- 
tinue after  removal  of  the  primary  cause  of  depression,  then  the  probability  is 
increased  that  we  are  dealing  with  an  abnormal  state  of  feeling. 


234         GEXKEAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  painful  state  of  feeling  that  occurs  in  healthy  individuals  is  not 
general,  and  may  still  be  influenced  in  a  certain  measure  by  pleasant  impres- 
sions, while,  on  the  contrary,  abnormal  painful  depression  changes  even 
pleasant  feelings  into  those  of  an  opposite  character,  and  recognizes  only 
variations  of  intensity.  There  are,  besides,  spontaneous  intensilication  of 
depression  to  intense  fear  and  anxiety;  troubles  due  to  inner  mental  and 
organic  conditions  which  are  foreign  to  the  emotional  states  of  healthy  indi- 
viduals, or  which  occur  only  in  obedience  to  external  causes.  The  abnormalry 
depressed  individual  also  has  not  infrequently  consciousness  of  the  disease 
that  threatens  him.  He  presents  disturbance  of  the  sensorium  (headache, 
dizziness,  sleeplessness,  feeling  of  inhibition  of  thought,  absence  of  thought, 
pressure  in  the  head  or  in  the  epigastrium),  hyperesthesias,  and  neuralgias. 

Too,  nutrition  suffers  more.  In  such  cases  the  body-weight  falls  much 
more  decidedly  and  quickly  than  in  those  affected  by  physiologic  depression. 

5.  After  the  symptoms  of  the  disease,  the  most  important  ele- 
ment is  its  eonrse.  In  general,  insanity  presents  definite  types  in  its 
course  that  have  been  empirically  established.  If  the  concrete  case 
correspond  with  the  empiric  laAvs  of  the  course  of  a  given  psychosis, 
then  it  is  certain  that  the  condition  is  abnormal,  and  the  more  if 
the  attacks  of  the  disease  occur  periodically  and  are  connected  Avith 
physical  conditions  which  coincide  (menses). 

But  the  disease-process,  in  so  far  as  expressed  in  symptomatic 
detail,  is  one  that  follows  empiric  laws,  even  though  our  scientific 
understanding  of  the  laws  governing  the  symptoms  and  their  oc- 
currence in  series  is  often  defective.  The  more  distinctly  single 
symptoms  show  inner  connection  and  foundation,  the  surer  is  the 
conclusion  that  the  process  is  abnormal. 

6.  In  insanit}',  as  in  other  diseases,  we  have  to  do  with  life 
under  abnormal  conditions.  The  functions  are  not  totally  changed, 
but  the  conditions  are  abnormal  under  which  they  manifest  them- 
selves; thus  it  necessarily  follows  that  it  is  not  the  altered  functions 
as  such,  but  the  reference  of  them  to  the  abnormal  conditions,  which 
is  essential.  The  distinction  between  an  individual  mentally  sound 
and  an  insane  person  is  essentially  that  in  the  former  the  psychic 
processes  are,  in  general,  in  relation  with  the  impressions  and  actual 
circumstances  of  the  external  world,  while,  on  the  contrary,  in  the 
insane  the  mental  activities  arise  out  of  inner  organic  abnormal 
conditions. 

They  are  the  expression  of  subjective  activities  which  have  no 
motive,  or  only  an  insufficient  one  in  consciousness  and  the  external 
world.  Therefore  the  content  of  psychic  activities  is  not  decisive,  but 
rather  their  origin  and  causation.  There  is  no  functional  disturb- 
ance that  occurs  in  the  insane  which  is  not  occasionally  observed 
within  the  limits  of  mental  health. 


GENERAL  DTAGNOSTS.  235 

7.  A  disease  is  always  a  complicated  process  -which  is  never 
manifested  in  a  single  symptom.  This  is  also  true  of  insanity.  The 
establishment  of  a  disease-picture  is  only  possible  synthetically.  Any 
single  symptom  only  becomes  valuable  and  worthy  of  consideration 
in  connection  with  other  symptoms  and  their  interrelations,  with 
correct  combination  and  interpretation  of  their  disparate  manifesta- 
tions, and  with  detailed  study  of  their  relation  in  time  and  their 
contradictory  association. 

Analytic  study  of  a  case  can  never  lead  to  the  desired  result,  the 
more  because  here  any  single  symptom,  even  if  it  be  a  delusion,  is 
equivocal.  This  is  even  still  less  possible  in  the  case  of  emotional 
anomalies,  affects,  perverse  impulses,  criminal  acts,  and  immoral 
tendencies,  which  can  be  estimated  only  in  relation  to  other  symp- 
toms and  the  previous  and  present  personality. 

8.  Insanity  as  a  disease  of  the  personality  requires  also  an  in- 
vestigation of  concrete  phenomena  singly. 

Si  duo  dicunt  idem,  non  est  idem.  Here  knowledge  of  the  indi- 
viduality is  indispensable.  In  the  mouth  of  a  man  highly  versed  in 
the  natural  sciences  belief  in  witches  would  be  very  suspicious,  as 
would  also  belief  by  an  astronomer  in  the  arrest  of  the  movement  of 
the  earth;  but  such  ideas  in  an  uneducated  person  would  not  seem 
so  remarkable. 

9.  Insanity  as  an  abnormal  phenomenon  of  life  makes  a  personal 
examination  of  the  patient  in  question  desirable.  Where  such  an 
examination  is  impossible,  as  in  case  of  an  opinion  given  in  absentia 
in  case  of  examination  of  the  mental  condition  of  a  person  already 
dead  to  determine  his  mental  condition  at  the  time  he  made  a  will, 
then  important  elements  for  diagnosis  are  wanting  (facial  expres- 
sion, Jiahitus,  etc.). 

Where  it  is  possible  to  make  a  personal  examination  it  is  of  great  im- 
portance to  be  able  to  observe  the  patient  in  question  imder  his  ordinary 
circumstances  of  life;  the  manner  in  which  he  lives,  dresses  himself,  and  em- 
ploys his  time  may  afford  important  elements,  not  only  in  relation  to  the 
insanity  itself,  biit  even  in  showing  the  manner  of  its  origin  and  manifestation. 
Conversation  with  the  patient  is  the  basis  of  a  mental  diagnosis.  It  is  neces- 
sary to  know  not  only  what  questions  to  ask,  but  also  how  the  conversation 
should  be  directed.  The  subject  of  the  examination  is  not  a  chemic  product, 
but  a  changeable  human  consciousness,  which  will  be  greatly  influenced  by  the 
manner  in  which  the  examination  is  conducted. 

The  examiner  should  approach  the  patient  in  the  simplest  possible  way, 
and  begin  the  conversation  with  the  most  indifferent  affairs,  leading  him  on  to 
speak,  without  allowing  him  to  divine  the  ultimate  object  of  the  examination. 
This  should  never  be  given  the  character  of  a  cross-examination.     It  is  best 


23()  GENERAL  PATHOLOOY  .\XD  THERAPY  OF  INSANITY. 

to  begin  with  Die  pliysical  Kondition,  ot-i-npation,  ami  earlier  life  history,  show- 
ing sympathy,  and  liius  gaining  the  contidence  of  the  patient.  Thus  the  his- 
tory, desires,  plans,  state  of  feeling,  intelligence,  and  tendencies  of  the  patient 
may  be  examined.  The  conversation  may  then  be  led  to  the  future;  family; 
social,  political,  and  religious  questions;  and  attention  should  be  directed  to 
determine  -whether  any  changes  of  relation  in  any  direction  are  present  which 
might  give  the  ■ke}'  to  any  possible  delusion.  As  a  rule,  an  insane  patient,  as 
soon  as  his  delusion  is  touched  upon,  rcNcals  it. 

During  this  e.xaniination  tlicrc  is  liiiic  to  ^imly  tlic  ghuuc.  niim.  gestures, 
and  attitiule.  and  take  in  the  home  and  surroundings. 

Tiie  mental  examination  is  to  be  foUowctl  by  a  careful  investigation  of 
all  the  bodily  organs  ami  functions. 

8tiuly  oi'  the  liaiulwritiiig  of  patients  is  an  important  help  in  tlio 
examination. 

The  maxim — "Le  style,  c'cKt  rjioiiinie"- — holds  good  here.  In  general,  it 
may  be  said  that  every  principal  form  of  mental  disease  has  certain  peculiari- 
ties of  writing  and  expression,  and  that  the  patient  in  his  writings,  where  he 
feels  less  under  observation,  gives  freer  expression  to  himself,  and  thus  be- 
trays more  than  in  conversation.  This  is  especially  true  of  patients  who 
obstinately  refuse  to  talk  because  of  delusions  and  imperative  voices  which 
command  them  to  be  silent.  It  is  also  often  astonishing  that  patients  who  are 
quite  rational  in  conversation,  in  their  writings,  both  for  themselves  and  for 
others,  express  the  most  irrational  ideas.  Writing  that  is  rational  does  not 
exclude  insanity  any  more  than  does  rational  speech.  The  writing  of  insane 
patients  may  reveal  delusions  otherwise  concealed;  the  stj-le  may  enable  a 
judgment  of  mental  capabilities,  and  in  its  outward  form  permit  a  conclusion 
concerning  the  state  of  consciousness;  and  the  writing  itself  may  be  of  un- 
portance  in  determining  the  existence  of  the  slighter  disturbances  of  co-ordina- 
tion. Imbeciles  write  the  least.  The  childish  formation  of  sentences,  awk- 
wardness and  lack  of  clearness  in  diction,  indicate  a  high  degree  of  mental 
weakness.  Since  writing  gives  greater  clearness  to  thought  tlum  does  speech, 
it  is  a  very  fine  test' of  states  of  mental  weakness  (Giintz).  Melancholic 
patients  also  write  little.  Here  mental  pain  and  inhibition  are  a  hindrance. 
The  monotony  of  thought  reveals  itself  in  the  continuous  repetition  of  the 
same  complaints,  fears,  and  self-accusations.  The  writing  does  not  flow  in  a 
stream;  it  can  be  seen  that  the  patient  overcame  liis  inliibition  only  spas- 
modically and  was  able  to  express  his  thoughts  only  in  fragments.  Not  in- 
frequently the  letters  themselves  are  written  with  a  trembling  hand. 

The  maniac  writes  much  with  a  firm,  steady  hand,  in  large  letters  and 
rapidly.  It  is  thus  a  true  picture  of  his  accelerated  thought,  which  oftentimes 
the  hand  is  rmable  to  keep  up  with ;  so  that  words  are  left  out  and  sentences 
remain  incomplete.  If  the  flight  of  ideas  become  greatly  intensified,  then  the 
liandwriting  degenerates  into  an  undecipherable  chaos  of  words  and  frag- 
mentary sentences  that  riui  into  each  other.  In  his  impulse  to  write  the 
patient  writes  in  all  directions  on  the  paper  and  does  not  trouble  liimself 
about  the  material  which  he  may  have  at  hand. 

Paranoiacs,  especially  the  querulous  and  erotic,  are  voluminous  writers. 
In  respect  to  their  handwriting,  changes  in  it,  curious  eccentricities,  curves, 
and  the  underlining  of  words  and  syllables  are  worthy  of  remark. 


CENERAL  D[A(;N<)SI8.  237 

The  diftion  may  bo  faiililoss,  Ixmihtisiic,  or  curious,  in  ncfcjrdiinff  willi 
the  natiii'e  of  tlic  (ioliisions  and  the,  state  of  eonsciousness.  Jn  such  cases  the 
most  reniari<able  peeuliai'ities  may  be  observed.  Thus,  ATaree  speaks  of  a 
paranoiac  who  had  a  peculiai-  idea  about  tiie  number  '.i,  and  in  wiitin;^  wi'ote 
each  letter  three  times. 

The  content  of  tlie  writings  of  paranoiacs  is  of  great  value,  since  it  often 
reveals  delusions  wliich  are  carefully  concealed  in  conversation. 

In  many  cases  the  writing  of  insane  patients  is  decidedly  incompre- 
iiensible,  as  the  result  of  employing  words  in  a  new  senses,  ti'anspfjsition  of 
syllables,  the  addition  of  senseless  syllables,  or  substitution  of  hieroglyphic 
and  symbolic  signs  for  letters.  In  such  cases  there  may  be  formation  of  new 
words  or  even  the  creation  of  a  kind  of  idiom. 

The  writing  of  patients  belonging  to  the  paralytic  group  presents  special 
peculiarities.  The  disturbance  of  co-ordination  finds  its  graphic  expression  in 
handwriting  that  is  indistinct  or  childish,  zigzag  or  tremulous,  and  without 
distinction  in  shading. 

Paragraphia  and  agraphia  are  frequently  observed,  expressed  in  words 
improperly  Avritten  or  in  the  absence  of  words.  The  amnesia  may  be  so 
marked  that  the  patient  repeats  several  times  a  word  written  or  even  com- 
jjlete  phrases.  The  great  distiu'bance  of  consciousness  prevents  recognition  of 
these  errors. 

In  addition,  while  writing,  the  patient  often  forgets  his  real  object,  so 
that  in  the  same  letter  he  addresses  himself  indifferently  to  several  persons. 
For  the  same  reason  it  sometimes  happens  that  the  patient  puts  whole  ex- 
tracts from  books  lying  near  him  into  his  letters,  or  that  he  writes  indifferently 
in  several  languages,  delivers  the  letter  unfinished,  and  forgets  to  put  the 
address,  the  date,  or  the  signature.  Too,  the  outer  appearance  of  a  letter, 
the  paper,  perhaps  found  in  the  swee"pings  and  covered  with  blots,  indicates 
clearly  the  great  distiirbance  of  consciousness. 

Among  the  sjaiiptoms  that  are  of  especial  importance  in  the  gen- 
eral diagnosis  of  insanity  there  are  still  to  be  mentioned :  the  trans- 
formation of  the  personality  (character)  into  a  new  abnormal  per- 
sonality and  the  presence  of  delusions  and  hallucinations.  Diagnosis 
by  the  laity  is  usually  limited  to  consideration  of  the  last  two 
elements. 

(a)  Change  of  Charactee. — The  fundamental  abnormal  proc- 
ess of  insanity  causes  changes  of  the  former  character;  that  is  to 
say,  of  former  habits,  inclinations,  efforts,  and  opinions — the  per- 
sonality becomes  another.  This  sjanptom  is  the  more  important, 
because  it  is  an  early  one  and,  as  a  rule,  precedes  delirium  of  thought 
and  act. 

This  pathologic  change  of  character,  which  may  go  to  the  extent 
of  complete  transformation  in  the  opposite  sense  of  former  opinions 
and  inclinations,  becomes  still  more  important  when  the  individiial 
lias  been  surrounded  by  conditions  or  influences  known  as  important 
causes  of  mental  disease. 


238  CEXP)RAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(b)  Delusions  are  frequeut,  but  by  no  means  absolute,  signs  of 
insanit}-.  It  would  be  a  great  mistake  to  recognize  insanity  only 
when  delusions  can  be  demonstrated.  The  patient  may  be  in  an 
initial  stage  (emotional),  in  which  delusions  are  not  yet  developed, 
or  he  may  present  a  fonu  of  insanity  in  which  delusions  are  never 
formed.  Too,  the  patient  may  be  able  to  conceal  his  delusions,  and 
these,  even  though  they  be  present,  are  not  always  present  in  con- 
sciousness. However,  when  the  existence  of  a  false  idea  is  demon- 
strated, it  must  be  studied  in  detail  in  order  to  determine  whether 
it  has  the  value  of  an  insane  delusion. 

(c)  Hallucinations — which  occur  in  other  cerebral  and  nerv- 
ous diseases,  in  fever,  and  in  intoxication — are  not  in  themselves 
decisive  as  to  the  existence  of  insanity.  The  most  that  they  prove  is 
the  existence  of  an  abnormal  cerebral  condition.  Their  significance 
as  one  of  the  symptoms  of  a  psychosis  depends  upon  the  demonstra- 
tion of  the  existence  of  a  psychosis.  Hallucinations  appear  in  their 
true  light  only  when  they  stand  in  relation  to  other  elementary  dis- 
turbances (depression,  attacks  of  anxiety,  etc.),  and  in  the  disturbed 
state  of  consciousness  are  no  longer  corrected  and  exercise  influence 
on  action. 

Suspicion  of  insanity  is  always  excited  if  hallueiuatious  are 
present,  especially  when  they  affect  several  senses. 

If  the  diagnosis  has  established  the  general  proof  of  insanity, 
then  the  further  qiiestion  arises  whether  it  be  an  independent  mental 
disease  or  a  S3'mptomatic  disturbance  of  the  mental  functions. 

The  circumstances  surrounding  the  origin  of  insanity,  its  pre- 
vious course,  and  exact  physical  examination  lead  to  the  solution  of 
this  question.  A  possible  confusion  with  typhoid,  with  an  insidious 
meningitis  (especially  tuberculous),  and  with  alcoholic  intoxication  is 
especially  to  be  kept  in  mind.  In  general,  the  latter  condition  is 
easily  distinguished;  still,  it  is  to  be  remembered  that  intoxication 
in  the  predisposed  may  run  the  course  of  acute  insanity  and  become 
the  exciting  cause  of  chronic  mental  disease. 

If  the  difficulties  of  distinguishing  actual  insanity  from  mere 
s}Tnptomatic  mental  disturbance  have  been  overcome,  then  the  ques- 
tion arises  whether  it  be  idiopathic  or  symptomatic. 

Etiology  and  pathogenesis,  with  the  peculiarities  of  the  disease- 
picture,  furnish  certain  points  of  departure.  Here,  along  with  the 
mental  disturbance  (primary  diminution  of  the  mental  powers,  dis- 
turbance of  memory,  grave  disturbances  of  consciousness,  unusual 
irritability),  the  physical  disturbances  (motor,  sensory,  especially 
anesthesia,   trophic,  fever,  and  subnormal  temperature)  make  tlj9 


GENERAL  DIAGNOSIS.  239 

distinction  possible.  In  general,  in  the  absence  of  signs  of  an  idio- 
pathic origin  of  the  trouble,  when  the  psychosis  can  be  genetically 
referred  to  a  peripheral  disease  (as  of  the  nterus,  the  alimentary 
tract,  etc.),  and  it  can  be  shown  that  the  former  has  arisen  in  the 
course  of  the  latter,  then  the  evidence  speaks  in  favor  of  the  trouble 
being  a  sympathetic  affection.  The  relation  is  clearest"  when  the 
peripheral  cause  induces  the  effect  periodically  (menstrual  insanity). 


CHAPTER  II. 


Diagnosis  of  Cure. 


Diagnosis  must  finally  be  extended  to. determine  whether,  after 
the  disappearance  of  mental  disease,  cure  has  resulted. 

The  question  may  arise  simply  with  reference  to  determining 
whether  a  patient  is  to  be  discharged  from  the  asylum,  and  also 
legally  with  reference  to  determining  whether  a  recovered  patient 
shall  be  reinstated  in  his  rights  of  citizenship  that  the  disease  may 
have  annulled. 

The  diagnosis  of  cure  is  not  surroimded  by  less  difficulty  than 
the  diagnosis  of  the  existence  of  the  disease;  especially  in  the  case 
of  ordinarily  weak-minded,  defective,  tainted  individuals  is  it  often 
scarcely  possible  to  determine  what  is  to  be  regarded  as  a  residuum 
of  disease  and  what  should  be  held  to  be  a  part  of  the  pre-existing 
abnormality. 

In  general,  the  diagnosis  of  cure  rests  upon  the  negative  ele- 
ments of  the  disappearance  of  all  symptoms  of  disease  and  on  the 
positive  element  of  restoration  of  the  former  mental  personalit}^  with 
all  its  peculiarities  of  character,  qualities,  faults,  and  inclinations. 
To  decide  the  latter  question  exact  knowledge  of  the  former  healthy 
or  relatively  healthy  individual  is  indispensable,  and  the  judgment 
of  relatives  is  often  surer  than  that  of  the  physician  in  the  asylum. 
In  deciding  whether  all  the  pathologic  S3^mptonis  have  disappeared, 
careful  consideration  of  the  course  of  the  disease  and  thft  present 
state  of  the  patient  is  necessary.  The  possibility  of  simply  temporary 
latency  of  the  disease  is  to  be  considered,  but  especiall}',  too,  the  con- 
cealment of  mental  symptoms  by  the  patient. 

It  is  still  more  important  to  observe  whether  the  mental  restora- 
tion has  taken  place  parallel  with  physical  recovery,  and  to  determine 
jt,s  relation  to  the  increase  of  body-weight. 


240  CEXERAI.  rATlI(t[.n(iV  AXD  TIIKK APY  OF  INSAMTV. 

An  iniportiint  critoi-imi  ol'  a  jisyeliie  kind  is  eniiiplclo  insiiilit  of 
the  recovered  individual  inlo  the  mental  disease  that  has  passed 
awa}'.  This  sjionld  apjiear  to  him  in  a  completely  objective  sense; 
but  this  criterion  has  its  liniit,  since  there  are  patients  who  recover 
and  who  have  no  memory  whatever  of  their  disease  (transitory  in- 
sanity) or  who  are  ashamed  lo  make  confession,  about  it.  Di^simula- 
lion  of  ])athologic  phenomena  occui's  in  the  melancholic  and  para- 
noiacs,  that  they  may  he  declared  well  and  discharged  or  in  order 
to  escape  the  control  of  a  guardian.  The  self-control  and  cunning 
of  such  patients  is  sometimes  truly  astounding. 

In  such  cases  careful  observation  of  the  course  of  the  disease  in. 
both  its  physical  and  psychic  aspects  is  the  most  important  point.  If 
this  be  wanting,  then,  by  kindness  and  friendship,  the  confidence  of 
the  patient  must  be  gained.  He  must  be  led  into  frank  conversation 
upon  all  possible  topics,  and  in  this  Avay  possible  affective  anomalies 
and  delusions  are  to  be  sought.  Too,  in  such  cases,  study  of  the 
handwriting  may  give  valuable  hints.  Not  less  important  is  study  of 
the  attitude,  the  inclinations,  and  the  acts.  To  experienced  observ- 
ers, peculiarities  of  dress,  conduct,  mimic,  and  gestures  become  val- 
uable elements  in  reachln"-  a  conclusion. 


Appendix. 

Outline  foe  the  Examination  of  the  Mental  Condition. 

I.  History. 

(A)    Gencaloijii  and  Health  of  the  Fninilij. 

Has  any  member  of  the  family  (ancestral,  collateral,  or  descendant) 
suffered  with  any  nervous  or  mental  disease?  In  what  relative,  from  wha.t 
cause,  and  at  what  age  was  the  nervous  or  mental  disease  observed  (cerebral 
disease,  spinal  disease,  hysteria,  hypoeh(.ndria,  epilepsy,  chorea,  migraine,  neu- 
rasthenia, psychoneuroses,  or  degenerative  psychic  disease)  ? 

Has  there  eyer  been  suicide,  drunkenness,  eccentricities  or  remarkable 
immorality  (crime),  ari-est  of  mental  development,  sudden  death  with  cerebral 
symptoms,  apoplexy,  convulsions,  deaf-mutism,  or  malformation  in  the  family, 
and  in  what  members  of  it? 

Were  the  parents  blood-relations?  Were  they  young  or  advanced  in 
years  at  the  time  of  the  birth  of  the  individual,  or  at  the  time  of  his  concep- 
tion intoxicated  or  convalescing  from  a  grave  disease  like  typhoid,  or  under- 
going some  depressing  cure  (mercury),  or  suflcring  from  tlie  efl'ect  of  other 
exhausting  inlluence? 

VVliich  of  the  parents  does  the  descendant  rcsciiiblc  i)liysi(;\lly  and  men- 
tally?    Is  there  tuberculosis  or  scrofula  in  the  family? 


GENERAL  DTACNOSIS.  241 


(B)  JTeaWi  and  Consiiiulion  of  llie  Individual. 

1.  Fetal  Life. 

What  was  tlie  state  of  the  mother's  healtli  during  pregnancy  (disease, 
injuries,  trouble,  excesses)?  Was  the  birth  at  term  or  premature?  Was 
there  any  head  injury  during  birth? 

,?.  ChiliUiood. 

Were  cerebral  attacks,  convulsions,  observed?  Had  these  any  influence 
upon  the  physical  and  mental  development?  When  did  the  teeth  appear? 
When  did  the  child  learn  to  walk  and  talk?  Was  there  somnambulism  and 
nocturnal  fears?  Did  the  child  have  children's  diseases,  especially  rickets? 
What  were  they,  and  what  were  their  results?  Was  the  child  subject  to  fear, 
nervously  excitable,  and  given  to  outbursts  of  anger? 

5.  FulKrftj. 

Was  the  physical  and  mental  development  precocious  or  retarded,  and 
was  the  mental  capacity  good,  mediocre,  or  bad?  At  what  period  did  the  signs 
of  puberty  appear?  When  did  the  menses  begin,  and  by  what  physical  and 
mental  disturbances  were  they  accompanied  (pain,  chlorosis,  nervous  disturb- 
ances, mental  depression,  hypochondria,  religious  exaltation)  ? 

Did  the  sexual  instinct  appear  abnormally  early  or  late  or  not  at  all, 
and  was  it  abnormally  intensified  or  perverse?  Was  it  satisfied,  and  how 
(onanism)  ?  At  the  time  of  pubescence  was  there  a  noticeable  change  of  char- 
acter or  an  attack  of  mental  disease? 

^.  Adult  Age. 

What  was  the  constitution,  strong  or  delicate?  Was  there  tendency  to 
disease  and  of  what  organ?  Was  there  actual  disease,  especially  anything 
like  head  injuries,  acute  diseases  like  typhoid,  intermittent  fever,  cerebral  dis- 
ease like  meningitis,  chronic  disease  like  chlorosis,  diseases  of  the  intestinal 
tract  or  of  the  uterus,  and  especially  constitutional  and  nervous  diseases  (lues, 
spinal  irritation,  hysteria,  hypochondria,  epilepsy,  etc.)?  What  wex'e  the 
principal  symptoms,  their  duration,  and  results?  Wliat  was  the  state  of  the 
functions  of  the  nervous  system?  Were  there  signs  of  a  neiu'opathic  constitu- 
tion (tendency  to  delirium  and  hallucinations  while  sick,  especially  Avith  fever; 
great  morbidity  in  general ;  unusual  reaction  to  atmospheric,  terrestrial,  and 
alimentary  influences;  idiosyncrasies;  lively  susceptibility  of  the  vasomotor 
system  to  mental  influences — paleness,  blushing,  palpitations,  and  sensations 
of  precordial  oppression;  intolerance  of  alcohol;  abnormal  states  of  drunken- 
ness; abnormal  excitability  of  the  sensory  and  sensorial  nerves;  unusual 
duration  of  excitement;  intercurrent  sensations;  intensified  reflex  excita- 
bility;   signs  of  irritable  weakness;    tendency  to  convulsions)? 

Are  there  signs  of  psychopathic  constitution  (great  irritability,  moral 
emotionality,  pathologic  afi'ects,  great  mobility  of  feeling,  frequent  groundless 
change  of  feeling,  changing  sympathies  and  antipathies,  great  excitability  of 
the  imagination,  great  excitability  of  the  will  without  perscA-erance)  ? 


243  GENERAL  PATHOLOGY  AND  TITFRArY  OF  INSANITY. 

What  was  the  general  psychic  character  (yielding  or  firm;  rational  ideas 
of  life  or  eccentricities  and  exaltations;  political,  religious  bigotry;  sociable 
or  unsociable;    egotistic  or  altruistic)? 

Is  the  temperament  phlegmatic  or  excitable,  sensitive  or  ambitious? 

The  intellect:  Harmonious  and  up  to  the  average  or  one-sided?  (Pre- 
dominance of  imagination  ^Yith  limited  understanding;  above  or  below  the 
average?  "What  have  been  tlie  social  relations?  Was  tlie  patient  satisfied 
with  the  position  in  wliich  he  grew  up?  The  family  relations,  especially 
marital?) 

What  have  been  the  occupation  and  manner  of  life  with  reference  to  any 
injurious  influences  (excesses;  onanism;  abuse  of  alcohol;  over-exertion; 
especially,  in  the  case  of  women,  the  menses;  with  reference  to  tlieir  recur- 
rence, quantity,  and  any  accompanying  nervous  and  mental  disturbances)  ? 
Has  the  patient  been  pregnant?  When  for  the  first  time,  and  how  often? 
How  rapidly  did  one  birth  follow  another?  What  was  the  state  of  mental  and 
physical  health  during  pregnancy?  Were  they  terminated  at  term  or  prema- 
turely; attended  by  complications  (artificial  aid,  hemorrhages,  etc.)  or  fol- 
lowed by  disease  (puerperal)?  Did  she  nurse  her  children?  How  often  and 
how  long? 

5.  Causes  of  the  Actual  Disease. 

Presumable  cause  of  the  present  disease?  ^^^^len  did  it  begin?  Investi- 
gation of  the  functional  disturbances  which  appeared  after  the  causes;  rela- 
tion and  manner  in  which  several  causes  may  have  produced  their  effect. 

6".  Prodromes  of  the  Actual  Disease. 

Is  the  present  psychosis  the  first  attack,  or  have  there  been  earlier  out- 
breaks of  mental  disturbance?  If  there  were,  wliat  were  their  cause,  symp- 
toms, course,  and  termination?  Did  the  present  disease  manifest  itself  sud- 
denly or  gradually?     "\Mien  and  with  what  prodromes? 

(a J  Loss  of  memory,  of  mental  power ;  mental  fatigue,  moral  inertia  with 
choleric  tendency;    change  of  character,  immorality? 

(bj  Painful  depression,  abnormal  sensitiveness,  emotional  irritability, 
sadness,  fear  of  becoming  insane,  disgust  of  life,  absence  of  pleasure  in  mental 
activity? 

(cj  Expansiveness,  loquacity,  too  busy  with  affairs,  tendency  to  travel, 
prodigality  in  spending  money? 

(d)  Hostile,  suspicious,  irritable  conduct,  jealous}-,  complaint  of  being 
despised,  of  being  cahuuniated  or  threatened? 

(e)  How  has  the  patient  slept,  eaten,  and  what  has  been  the  state  of 
excretion,  menstruation  ?  Have  there  been  headache,  vertigo,  precordial  sensa- 
tions, neuralgia,  disturbances  of  speech?  Have  there  been  apoplectiform  or 
epileptiform  attacks  or  attacks  of  dizziness? 

(f)  Were  these  prodromes  continuous,  remittent,  or  intermittent?  How 
did  one  follow  another? 

II.  Present  Condition. 

(A)  Physical  Examinaiion. 

1.  Physical  size,  weight,  state  of  nutrition,  the  amount  of  blood,  its  com- 
position and  distribution,  cyanosis,  fluxion,  local  anemia.     Age,  with  especial 


GENErJAL  DTAOXOSTR.  21^ 

reference  in  youthful  individuals  as  to  whether  the  development  of  the  body 
corresponds  with  age;  in  adults  as  to  whether  any  signs  of  old  age  or  de- 
crepitude are  due  to  the  age. 

2.  Form  and  size  of  the  cranium.^ 

(aj  Circumference    iiieasurenicnts    (taken    witli    a    tape 
measure)    in    centimeters:    Horizontal    circumference 
through  the  external  occipital  protuberance  and  the    Male.       Female. 
glabella    55      cm.        53      cm. 

Posterior  occipital  line,  from  the  border  of  the  mastoid 
process  on  one  side  over  the  external  occipital  pro- 
tuberance to  a  corresponding  point  on  the  other 
side 24      cm.        22      cm. 

The  anterior  frontal  line,  from  the  anterior  border  of 
the  external  auditory  canal  of  one  side  over  the 
glabella  to  like  point  on  the  opposite  side 30      cm.        28      cm. 

Vertical  line,  from  the  root  of  the  zygomatic  process 
of  one  side  over  the  vertex  to  a  corresponding  point 
on  the  other  side 36      cm.        34      cm. 

Longitudinal  circumference,  from  the  root  of  the  nose 

to  the  external  occipital  protuberance.  . 35      cm.        33      cm. 

The  ear-chin  line,  from  the  external  auditory  canal  on 
one  side  over  the  point  of  the  chin  to  a  corresponding 

point  on  the  opposite  side 30      cm.        28      cm. 

(Jjj  Calliper  measurements:  Longitudinal  diameter,  from 
the  root  of  the  nose  to  the  external  occipital  pro- 
tuberance        18      cm.        17.5  cm. 

Greatest  lateral  diameter 15      cm.        14      cm. 

Diameter  between  the  external  auditory  canals 12.5  cm.        11.5  cm. 

Diameter  between  the  zygomatic  processes  of  the 
frontal  bone 11      cm.        11      cm. 

Distance  from  the  auditory  meatus  to  the  nasal  spine.     12      cm.        11      cm. 

Breadth,  index:  i.e.,  the  product  of  dividing  the  longi- 
tudinal diameter  by  the  lateral  diameter,  multiplied 
by   100 SO  70 

3.  Signs  of  degeneration:  (a)  Cranial  anomalies:  Microcephaly,  niacro- 
cephaly,  cephalonia,  and  hydrocephalus  (rhombo-,  lepto-,  and  klino-  cephalus). 

(1))  Eyes:  Congenital  blindness,  retinitis  pigmentosa,  eoloboma  iridis, 
albinism,  difference  in  the  pigmentation  of  the  iris,  congenital  strabismus, 
obliquity  of  the  opening  of  the  eyelids. 

^  The  average  measurements  given  above  are  taken  from  Welker's  meas- 
urements on  the  bony  skull,  modified  by  Dr.  Muhr  for  the  head  of  the  living. 
In  the  insane  the  cranial  measurements  of  most  importance  are  those  for  de- 
termining the  relations  of  size  and  deformities.  Macrocephalic  heads,  after 
excluding  cephalonia,  as  well  as  microcephalic,  give  rise  to  the  presumption  of 
congenital  or  early  acquired  states  of  imbecility  and  mental  weakness.  De- 
formities of  the  skull  and  ineqiuility  of  development  of  its  two  halves  seem  to 
predispose  to  brain  diseases.  They  are  remarkably  frequent  in  paranoiacs; 
not  infrequently  they  are  dependent  upon  rickets.  Other  traces  of  rickety 
should  be  looked  for  in  the  rest  of  the  skeleton. 


24A  HFAERAL  PATllOI^OOY  AXD  TTIEI^APY  OF  INSANITY. 

(r)  Nose:  Obliquity  of  l}ie  nose,  great  depth  of  tlic  root,  of  tlie  iiosc 
(ere  tin  ism). 

(dj  Ears:  Too  small,  too  large  car;  rudimenlary  lobule  or  one  wliieh  loses 
itself  in  the  surrounding  skin;  dcfeelive  dill'crentiation  of  the  helix,  antihelix, 
tragus,  and  antitragus. 

(cj  Defective  dill'erentiation  of  the  teeth;  total  or  partial  absenee  of  the 
second  dentition";    abnormal  position  of  the  teeth  (rickets). 

(fj  Mouth  and  palate:  Too  large  or  too  small  a  mouth;  too  high  and 
narrow  or  too  low  and  wide  a  palate,  or  a  palate  flattened  on  one  side:  defect 
of  the  palatal  tissues — hai'dij),  eleft  palate;  prominence  of  tlie  intermaxillary 
bone. 

(</)  Skeleton  and  extremities:  Ilmnpbaek,  elub-foot,  club-lKuul,  iin(M|ual 
size  of  the  hands,  supernuuierary  lingers  and  toes. 

(h)  (Jenitals:  Crypt  dichy.  epi-  amt  iiypo-  s|iadiasis,  or  lierni.i|ilir()ditism  : 
uterus  infantilis,  bieorni>,  etc.:  phimosis  witlujul  liyix'rtmpliy  or  lengthening 
of  the  foreskin. 

(ij  The  hair:  Abnormal  giowth  of  hair  in  women;  marked  growth  of 
hair  over  the  body. 

4.  Temperature   (thermometer). 

5.  Pulse:    Frequency,  quality   (slowness  or  acceleration);    sphygmogruph. 

6.  Examination  of  tlie  functions  of  the  higher  sense-organs  (ophthalmo- 
scope, etc.). 

7.  Examination  of  sensibility:  Hyperesthesia,  anesthesia,  nem-algias 
(esthesiometer,  needle,  electric  ciurent). 

8.  Examination  of  the  superficial  and  deep  reflexes. 

9.  Kxamination  of  the  motor  functions:  Facial  innervation,  mydriasis, 
inequality  of  the  pupils,  reaction  of  the  iris  (atropine,  calabar),  nystagmus, 
strabismus,  paralysis  of  ocular  uuiscles,  ptosis,  speech  (aphasia,  ataxia, 
paralysis  of  the  tongue),  ataxia,  tremor,  paresis,  paralysis  of  the  extremities, 
or  sphincters,  catalepsy,  hypertension  of  muscles. 

10.  Secretory  functions:    Salivation,  perspiration,  examination  of  urine. 

11.  Trophic  condition  of  the  skin,  decubitus,  othematoma. 

12.  Physical  examination  of  the  organs  of  the  chest  and  abdomen;  in 
women,  determination  of  the  position  and  functional  condition  of  the  uterus. 

1.3.  Attitude,  glance,  mien,  gestures. 

14.  Sleep,  appetite. 

15.  Functions  of  the  sensorium:  dizziness;  feeling  of  trouble  in  the  liead, 
of  changed  weight,  or  of  its  circumference  as  greater  or  smaller. 

(B)  Mental  Examination. 

1.  State  of  feeling,  fundamental  feeling,  change  of  feeling,  state  of  emo- 
tional excitability,  manner  of  reaction  to  external  events,  whether  increased 
or  diminished.  Consideration  whether  mental  impressions  or  sense-perceptions 
emphasize  mental  feelings,  and  what  their  quality  is. 

2.  Thought:  Whether  slowed  or  increased  in  rapidity;  whether  inter- 
rupted;   flight  of  ideas;    incoherence;    imperative  ideas. 

3.  Consciousness:  Whether  troubled  and  in  what  diicction;  conscious- 
ness of  time,  place,  of  personality. 

4.  Memory:  Whether  intensified  or  diminished,  partially  (for  late 
events)  or  as  a  whole. 


GENEllAL  DTACNORTR. 


24. 


5.  Sense-perceptions:    Whether  intensified  or  slow,  distorted  or  absent. 

6.  State  of  thought:  Manner  in  wiiich  logical  processes  are  carried  out, 
capacity  for  mental  work  in  general,  especially  witli  refeience  to  intensity 
(clearness)  and  duration  (rapid  exhaustion). 

7.  State  of  ethic  consciousness:  Presence  and  valuation  of  nioi'al  ideas 
and  judgments. 

8.  State  of  the  will:  Whether  intensified  impulse  to  activity  or  dimin- 
ished (abulia). 

9.  Presence  of  delusions  and  hallucinations. 


PART  FIFTR 
General   Therapy. 


CHAPTER  I. 
General  Considerations. 

The  fact  that  insanity  is  a  cerebral  disease  and  curable  when 
early  recognized  and  properly  treated  has  only  been  realized  of  late. 
Even  as  late  as  the  preceding  century  ignorance  and  cruelty  incar- 
cerated the  troublesome  insane  in  prisons  and  houses  of  detention 
along  with  criminals  and  vagabonds  or  allowed  them  to  perish  in  filth 
and  misery.  It  was  scarcely  a  greater  disgrace  to  be  a  criminal  than 
to  be  insane. 

It  was  reserved  for  modern  times,  after  many  errors  concerning  the 
nature  of  insanity,  and  after  long  and  unprofitable  discussion  as  to  whetlier 
the  soul  or  the  brain  was  diseased,  or  both,  to  reach  more  correct  views  con- 
cerning the  nature  and  treatment  of  this  condition.  The  scientific  recognition 
of  insanity  as  a  disease  of  the  brain  permitted  the  humane  conviction  that  so 
great  a  human  misfortune  was  worthy  of  the  protection  and  help  of  society, 
and  that  society  should  not  simply  incarcerate  the  most  unfortunate  of  its 
members.  The  first  result  of  these  scientific  and  humanitarian  eft'orts  was  the 
institution  for  the  insane.  With  its  origin  begins  the  rational  therapy  of 
insanity. 

Therapy  as  we  practice  it  to-day  does  not  trouble  itself  in  any  way  about 
the  impractical  metaphysical  question  whether,  above  the  brain,  there  is  a 
special  soul  or  whether  the  therapy  should  be  exclusively  physical  or  mental. 
Recognition  of  the  fact  that  all  mental  manifestations  are  functions  of  the 
brain  leads  us  to  attempt  to  aflfect  the  abnormal  mental  condition  h^  means 
of  psychic  infiuence,  in  awakening  feeling,  thought,  and  will;  just  as  the  fact 
that  insanity  depends  upon  anatomic  processes  in  the  brain  justifies  an  at- 
tempt to  overcome  the  disturbance  of  cerebral  functions  by  physical  and 
medical  measures. 

Thus  the  need  of  physical  and  mental  treatment,  and  the  necessity  of 
tlieir  combination,  seem  to  be  the  fundamental  principle  of  the  therapy  of 
insanity. 

That  this  may  be  fulfilled  it  is  necessary  thoroughly  to  investigate  the 
disease,  the  personality  in  all  its  present  and  past  relations,  the  character,  the 
inclinations,  and  the  habits  of  life,  as  the  basis  of  a  mental  therapy,  which 
cannot  be  thought  of  except  as  individualized;    and  this  must  be  completed 

(24Ü) 


GENERAL  THERAPY.  2-L7 

by  the  previous  liistory  of  the  physical  (.■ondition,  former  diseases,  and  patho- 
logic disposition,  and  the  circumstances  and  causes  of  tlie  present  disease,  with 
its  course  and  its  actual  manifestations. 

There  must  next  be  a  clear  understanding  of  the  etiology  and  character 
of  the  actual  disease;  whether  it  is  idiopathic,  and  what  changes  in  the  brain 
may  lie  at  its  foundation;  or  whether  it  be  sympathetic,  and  what  general 
disturbances  of  nutrition  or  local  afl'ections  of  the  vegetative  organs 
influence  it. 

If  an  anatomic  diagnosis  (hyperemia,  anemia,  infkuiiniation,  etc.)  is  not 
possible,  then  at  least  a  functional  diagnosis  should  be  made,  and  all  the 
functional  disturbances  present  should  be  placed  in  a  clear  light. 

Diagnosis  of  the  so-called  forms  of  disturbance  has  at  least  clinical  value, 
though  it  cannot  bear  upon  therapy. 

Psychiatry  has  never  anything  to  do  with  forms  of  disease^  but 
always  and  only  with  the  abnormal  individual.  In  contrast  with  the 
majority  of  diseases  of  the  vegetative  organs,  in  which  the  patho- 
logico-anatomic  process  and  often  the  physical  constitution  must  be 
taken  into  consideration,  psychiatry  individualizes  strictly. 

The  important  point  of  therapy  lies  in  the  history  of  pathogen- 
esis and  the  etiology  -of  the  individual  case.  In  the  domain  of 
psychiatry  special  methods  of  cure  and  fixed  systems  of  treatment 
are  only  applied  by  slaves  of  routine  and  charlatans. 

All  the  interest  lies  in  individualizing  the  treatment  of  the 
insane  person,  and  also  all  the  difficulty  of  therapy,  especially  when 
this  is  purely  mental.  Since  insanity  is,  for  the  most  part,  chronic 
and  continues  months  and  even  years,  we  have  ample  time  to  investi- 
gate the  circumstances  and  nature  of  the  case,  and  there  is  no  need 
to  hurry  in  our  medical  interference.  In  the  rare  cases  in  which 
insanity  occurs  acutely  and  runs  a  rapid  course,  active  therapy  has 
but  little  effect  upon  the  typic  course  of  the  disease-picture.  Even 
when  the  concrete  case  is  pathogenically  and  clinically  clear,  active 
therapy  has  but  a  limited  application.  Very  rarely  can  the  diagnosis 
become  anatomic,  and  even  when  this  is  possible  it  is  a  question 
whether,  with  the  means  we  have,  we  can  affect  the  progress  of  the 
cerebral  process. 

Thus  it  happens  that  the  task  of  the  alienist  is  essentially  to 
overcome  causal  and  complicating  disturbances  in  other  organs;  to 
improve  the  circulation,  nutrition,  and  excitability  of  the  diseased 
brain  by  dietetic  and  appropriate  physical  measures;  and  on  the 
psychic  side,  by  regulating  rest  and  activity  and  exciting  feeling, 
thought,  and  will  attempt  to  influence  favorably  the  diseased  brain. 
At  the  same  time  he  should  seek  to  overcome  certain  s^onpathetic 
elementary  disturbances,  such  as  sleeplessness,  refusal  of  food,  hal- 
lucinations, etc.,  which  are  troublesome  or  dangerous. 


248       CEXKl^^L  patholocy  and  therapy  of  insanity. 

If  our  therapeutic  powers  at  the  height  of  the  disease  are  con- 
fined within  narrow  limits,  still  psychiatry  has  before  it  a  noble  work 
in  teaching  and  practicing  the  prophylaxis  of  such  diseases. 


CHAPTER  11. 
Prophylaxis  of  Insanity. 

The  etiology  of  insanity  reveals  the  injurious  influences  out  of 
which  insanity  develops.  j\rany  of  these  are  avoidable.  It  lies  with 
society  as  well  as  the  individual  to  avoid  the  most  potent  oE  these 
causes,  among  which  may  be  mentioned  hereditary  transmission  and 
sexual  and  alcoholic  excesses. 

i'^requently  the  physician  is  in  a  position  to  save  individuals 
from  threatened  disease  who  have  inherited  from  their  tainted  par- 
ents a  predisposition  to  insanity;  but  for  this  he  must  have  a 
psychiatric  education. 

In  this  sense  the  task  of  prophylaxis  is  worthy  and  productive, 
for  predisposition  is  not  yet  disease,  and  it  is  still  possible  by  weak- 
ening it  and  creating  greater  power  of  resistance  to  injurious  influ- 
ences, or,  by  avoiding  the  latter,  to  prevent  the  misfortune.  In  the 
education  and  treatment  of  such  neuropathic  or  otherwise  tainted 
children,  the  following  points  are  to  be  considered: — 

Hygiene  must  begin  while  the  child  is  still  at  its  mother's  breast. 

Such  children  should  not  be  artificially  nurtured;  nor  should 
they  be  nursed  by  a  mother  whose  neuropathic  and  anemic  condition 
afllords  bad  nourishment.  When  it  is  possible  the  child  should  be 
nursed  by  a  woman  mentally  and  physically  healthy,  at  least  until 
the  end  of  the  ninth  month. 

Too  warm  rooms  should  not  be  allowed  nor  too  -warm  clothing. 
The  temperature  of  the  bath  should  be  26°  E.  (90.5°  F.),  and  after 
a  few  months  it  should  be  lowered  to  23°  E.  (83.25°  F.). 

During;  the  dangerous  period  of  the  first  dentition  all  hygienic 
measures  should  be  very  strictly  enforced  in  order  to  avoid  as  far  as 
possible  brain  hyperemia  and  convulsions,  which  at  this  time  are 
so  frequent  and  dangerous. 

These  children  should  be  fortified  as  soon  as  possible  by  cold 
baths  and  life  in  the  open  air.  The  nourishment  should  be  fortifying 
and  not  exciting,  with  avoidance  of  coffee,  tea,  and  alcohol. 

Attention  to  the  development  of  feeling  and  character  cannot 
begin  too  early.     The  children  should  be  early  accustomed  to  obedi- 


GENERAL  THERAPY.  249 

encG;,  and  their  morals  should  be  strengthened,  while  passions  and 
sensitiveness  should  be  repressed,  and  calm  and  self-control  under 
the  varying  events  of  life  should  be  inculcated.  , 

The  majority  of  tainted  children  show  abnormal  intellectual  de- 
velopment: either  it  is  precocious,  in  Avhich  case  it  should  be  re- 
strained, or  it  is  retarded,  and  then  patience  is  necessary.  All  cere- 
bral strain  should  be  avoided.  Such  children  should  be  sent  to  school 
late,  since  mental  strain  is  not  good  for  them.  At  the  proper  time 
a  simple  or  technical  occupation  should  be  chosen  for  them,  thus 
avoiding  the  dangers  of  a  college  training  and  later  those  of  a 
sedentary  life  vs^ith  too  much  mental  strain. 

If  the  parents  be  perverse,  hypochondriac,  or  hysteric,  it  is  better 
to  educate  the  child  away  from  home  in  order  to  avoid  the  danger  of 
defective  education  or  transference  of  the  mental  infirmities  of  the 
parents  by  imitation.  Education  in  boarding-schools  is  not  appro- 
priate for  such  children  for  various  reasons.  The  best  education  for 
them  is  that  obtainable  in  the  home  of  a  teacher  or  a  pastor. 

Special  care  must  be  given  to  any  possible  aberrations  of  the 
sexual  instinct,  which  in  such  predisposed  individuals  often  appears 
early  and  is  excessive;  everything  that  tends  to  development  of  the 
sexual  sphere  must  be  carefully  kept  from  influencing  the  child. 

Tainted  individuals  require  special  medical  attention  during  the 
period  of  puberty,  which  is  in  itself  so  dangerous,  as  are  in  general 
all  the  physiologic  phases  of  life.  The  slightest  physical  disease 
occurring  at  this  time  may  complete  the  chain  of  etiologic  elements 
and  cause  the  outbreak  of  insanity.  All  such  diseases  (chlorosis,  etc.) 
demand  the  most  careful  investigation  and  energetic  treatment. 

On  the  mental  side,  the  reading  of  novels  of  all  kinds  and  too 
lively  and  enthusiastic  cultivation  of  religion  are  especially  dan- 
gerous. In  males  early  marriage  diminishes  the  danger  of  disease. 
In '  females  marriage  is  advantageous  only  after  full  physical  ma- 
turity; otherwise  there  is  the  danger  that  pregnancy  and  the 
puerperal  period  may  be  associated  with  an  undeveloped  weak  body, 
and  thus  induce  insanity.  Kursing,  even  when  it  is  permissible, 
should  be  carefully  watched,  and  it  should  never  be  continued  longer 
than  three  months.  The  dietetic  and  medical  treatment  during  the 
puerperal  state  must  be  fortifying. 

During  the  period  of  mature  life  the  maintenance  of  equilib- 
rium of  the  mental  functions  would  be  favored  by  the  choice  of  an 
appropriate  occupation,  not  too  exciting,  which  avoids  the  influence 
of  changes  of  fortune,  the  stock  exchange,  or  a  business  life.  At 
the  same  time  a  manner  of  life  in  conformity  with  Nature  must  be 


O50    GENERAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

followed,  avoiding  the  use  ol  alcohol  and  taking  into  aeroiint  the 
functions  of  the  digestive  organs. 

In  many  cases  the  accomplishment  of  these  requirements  will 
prevent  the  development  of  mental  disease  in  those  predisposed. 


CHAPTER  III. 
Treatment  in  the  Initial  Stages  of  Insanity. 

Insanity  seldom  comes  like  a  thunderbolt  out  of  a  clear  sky. 
For  the  most  part,  it  develops  slowly  in  the  course  of  months  or 
years.  This  is  the  important  period  in  which  to  overcome  the  germi- 
nating misfortune.  If  the  physician  be  an  alienist  he  clearly  recog- 
nizes the  commencing  insanit}»^,  when  the  inexperienced  sees  only 
physiologic  depression  and  disappointed  love,  or  chlorosis,  hysteria, 
hypochondria,  nervous  weakness,  excited  nerves,  or  other  commonly 
diagnosticated  states. 

Unfortunately  very  frequently  the  uncertainty  of  the  physician 
in  psychiatric  matters  allows  this  stage  to  pass  unnoticed  and  un- 
treated, and  only  the  so-called  sudden  outbreak  of  the  disease  opens 
his  eyes. 

When  fortunately  the  disease  is  recognized  early  in  its  incipi- 
ency,  in  a  great  number  of  cases  it  is  still  possible  to  prevent  the 
catastrophe. 

The  first  conditions  of  successful  treatment  are  the  recognition 
of  the  causes  and  their  removal.  Both  psychic  and  physical  thera- 
peutics have,  under  such  circumstances,  a  wide  field  of  application. 
In  one  case,  perhaps,  it  is  unfortunate  household  conditions  or  over- 
work; in  another,  anemia,  disturbances  of  menstruation,  uterine  dis- 
ease, catarrh  of  the  stomach,  etc.,  that  must  be  overcome.  It  is  a 
matter  of  tact  and  medical  diagnosis  to  do  the  proper  thing.  In 
general  the  following  indications  may  be  laid  down : — 

1.  Cessation  of  occupation.  The  patient  must  give  up  all  strain. 
Usually  the  best  etfect  is  derived  from  a  pleasant  sojourn  in  the 
country  with  acquaintances  and  relatives  or  from  travel.  Long  jour- 
neys must  be  avoided,  as  well  as  noisy  cities  and  gay  watering-places. 
Change  of  surroundings  is  even  more  necessary  if  local  conditions  in 
the  family  or  social  relations  have  induced  or  favored  the  occurrence 
of  the  disease. 

2.  Avoidance  of  all  weakening  influences.  Insanity  is  accom- 
panied by  profound  disturbances  of  nutrition,  and  induces  them. 

3.  Fortifying,  but  unirritating,  nourishment.  Alcohol,  as  well 
as  strong  cigars,  should  be  avoided. 


GENERAL  THERAPY.  251 

4.  Eegulation  of  Die  s(;(;i'(:tioiis,  es()0(;ially  daily  altoDÜoTi  to  tlie 
towels.  Drastic  cathartics  sliould  not  be  prescribed,  but  enemas, 
aloes,  rhubarb,  podophyllin,  and  salines  with  dietetic  measures  (cream 
of  tartar,  grapes,  wheys,  etc.). 

5.  Attention  to  the  cerebral  functions  in  general,  especially  to 
sleep;  and  any  possible  disturbances  of  the  cerebral  circulation  must 
be  overcome.  Sleeplessness  may  be  overcome  by  baths,  wet  packs,  amyl 
hydrate,  sulphonal,  or  trional,  which  may  be  tcnipovarily  employed. 
Opiates  alone  or  in  combination  with  quinine  or  digitalis,  with  laurel- 
water  or  bromine  salts,  may,  according  to  circumstances,  be  useful. 

The  disturbances  of  the  circulation  that  occur  at  this  time  are, 
for  the  most  part,  hyperemias  due  to  diminished  vasomotor  innerva- 
tion. They  demand  a  tonic  regime,  and  they  should  be  treated  with 
cold  packs,  icebags,  dry  cupping,  or  sinapisms  to  the  back  of  the  neck, 
lukewarm  baths  (especially  where  the  heart's  action  is  excited)  up  to 
25°  K.  (88°  F.),  and  hand-  and  foot-  baths. 

6.  The  physician  should  be  ex^Derienced  in  the  treatment  of 
mental  cases  and  possess  the  confidence  and  obedience  of  the  patient. 
He  should  know  how  to  distract  and  amuse  him.  The  conduct  of 
those  surrounding  the  patient  should  be  known  and  Avatched  (excel- 
lent suggestions  are  found  in  articles  by  Schröter  and  Hecker).  The 
patient  should  not  be  subjected  either  to  moralizing  or  criticism. 

Logical  dialectic  opposition  to  his  erroneous  ideas  is  quite  as 
much  to  be  avoided  as  acquiescence  in  them.  Such  efforts  are  only 
harmful  in  that  they  irritate,  embitter,  and  intensify  ideas  that  de- 
pend upon  a  brain  disease.  In  a  word,  the  patient  should  be  left  at 
rest,  and  he  should  be  opposed  only  when  he  is  intractable  to  treat- 
ment, and  even  then  one  should  proceed  quietly  and  kindly,  never 
with  cunning.    The  patient  should  never  be  left  to  himself. 

7.  In  case  the  insanity  begins  as  melancholia  and  with  symptoms 
of  mental  hyperesthesia,  with  or  without  precordial  anxiety,  opiuni 
is  an  excellent  medicine  the  value  of  which  cannot  be  over-estimated. 

In  the  majority  of  cases  this  excellent  advice  remains  nothing  more  than 
a  pious  wish.  If  the  physician  has  recognized  the  disease  too  late,  he  finds 
himself  without  the  power  to  act,  or  he  avails  himself  of  certain  obsolete  pre- 
scribed methods  of  treatment  which  are  actually  harmful  and  which  Erlen- 
meyer  has  condemned  as  the  result  of  wide  experience.  The  patient  is  treated, 
or  rather  maltreated,  by  a  system  of  privation,  mild  diet,  bleeding,  pui-gatives. 
derivatives,  etc.;  or  he  is  sent  to  a  cold-water  cure,  where  he  shivers  and  is 
mercilessly  douched,  and  his  strength  reduced;  or  he  is  subjected  to  a  treat- 
ment by  tartar  emetic  or  psychic  or  mental  shock;  or,  again,  an  effort  is  made 
to  distract  him,  and  the  excited  or  depressed  patient  in  need  of  rest  is  made 
to  travel,  taken  to  theaters  and  concerts,  or  forced  into  society.     Here  should 


253  GENERAL  PATIKILOCY  AND  THERAPY  OF  INSANITY. 

be  inontioned  also  the  modern  beniiiuUing  treatment  with  chloral  and  sul- 
phonal,  used  by  so  many  ifjnorant  physicians,  even  to  the  extreme  of  poison- 
ing the  patient. 

Finally  the  patient  becomes  maniacal,  stupid,  or  obstinate,  and  at  last 
private  treatment  is  recognized  as  no  longer  efficient,  and  the  asylum  is 
thought  of,  where  the  patient  arrives  frequently  enough  in  an  incurable  con- 
dition. 

Thus  the  fate  of  the  unfortunate  insane  is  sealed  when  they  fuuilly  reach 
the  hands  of  the  alienist,  tlieir  disease  iiaving  become  incurable  as  the  result 
of  ignorance  of  2)h}sicians  and  tlie  fatal  prejudice  against  asyliuns.* 

Decision  of  the  question  at  the  right  time  whether  and  when 
private  treatment  is  no  longer  useful  and  asylum  treatment  is  neces- 
sary is  of  the  greatest  importance. 


CHAPTER  IV. 
'  The  Hospital  for  the  Insane. 

Fktghtful  for  the  laity,  the  institution  for  the  insane  is,  in  the 
opinion  of  the  alienist,  the  most  important  means  of  cure  of  insanity. 
It  is  only  there  that  the  patient  finds  effectual  protection  against 
dangers,  especially  suicide.  Here  he  can  act  as  he  desires  without 
moralizing,  without  correction  or  teaching;  and  he  finds  care  and 
benevolence  and  a  greater  amount  of  freedom  than  could  possibly  be 
allowed  him  in  the  family,  with  every  curative  means  at  hand,  and 
possibility  of  amusement  and  distraction  in  so  far  as  he  is  capable 
of  them. 

Of  course,  he  must  submit  to  the  authority  of  the  physician  and 
the  rules  of  the  institution,  but  as  soon  as  he  comes  to  himself  he 


^Neumann  very  well  says  ("Psychiatrie,"  page  194) :  "A  great  number  of 
patients  whose  admission  to  asyhuns  is  demanded  are  already  actually  lost. 
The  fault  lies  partly  with  the  family  and  partly  with  the  physician.  The 
family  is  long  in  reaching  a  conclusion  that  the  patient  is  really  ill,  and  the 
physician  requires  a  long  time  to  reach  the  conclusion  that  the  patient  is  in- 
sane; and  then  the  two  together  require  a  long  time  before  they  decide  that 
an  alienist  is  necessary. 

"The  first  period  of  this  delay  is  used  to  trouble  and  irritate  the  patient 
with  distraction,  persuasion,  advice,  criticism,  etc.  During  the  second  period 
the  irritation  is  combated  by  bleeding,  cathartics,  stimulation  of  the  skin,  and 
artificial  induction  of  suppuration;  during  the  tlürd  period  both  parties 
wonder  why  the  means  employed  have  produced  no  result.  Finally  the  alienist 
arrives,  to  find  the  strength  of  the  patient  exhausted,  his  digestion  destroyed, 
mental  excitement  at  an  acme,  or  in  the  deepest  melancholy,  often  even  with 
the  insane  condition  bordering  upon  incoherence.  At  this  point  the  alienist 
is  asked  to  help  the  patient." 


GENERAL  THERAPY.  253 

recognizes  the  benevolent  spirit  that  animates  it  all.  Proleftinn 
against  clangers  and  the  powerful  mental  and  physical  means  of 
cure  found  in  a  hospital  are  the  advantages  which  the  latter  has  over 
private  treatment,  which  has  to  contend  with  tlie  resistance  of  the 
patient,  the  ignorance  of  the  relatives,  and  the  absence  of  proper 
space  and  other  means. 

But  the  hospital  for  the  insane  is  not  infrequently  a  direct 
means  of  cure,  in  that  the  transference  of  the  patient  to  other  and 
well-adapted  surroundings  fulfills  the  causal  indication  and  removes 
the  abnormal  influence  of  excesses,  occupation,  or  unfavorable  cir- 
cumstances of  family  life. 

In  general,  patients  have  only  pleasant  impressions  of  the  asylum;  and, 
as  a  rule,  those  that  recover  remember  with  gratitude  the  asylum  to  which 
they  owe  their  cure.  Statistics'  clearly  show  that,  the  earlier  the  patient 
enters  the  asylum,  the  greater  is  the  probability  of  recovery. 

Unfortunately  there  are  many  traditional  prejudices  against  the  early 
employment  of  the  asylum  as  a  means  of  cure.  The  laity  think  that  patients 
must  become  ripe  for  the  asylum — i.e.,  incurable;  and  thus  it  happens  that 
the  asylums,  as  Maudsley  cleverly  expresses  it,  are  rather  burying  grounds  for 
ruined  minds  than  asyhuns  for  brain  diseases.  It  is  thought  that  the  pa- 
tient, by  living  together  with  other  patients,  can  only  become  worse.  Experi- 
ence teaches  the  contrary.  Patients  have  their  attention  directed  to  them- 
selves by  the  treatment  which  they  see  others  have,  and  thus  to  their  own 
condition,  and  the  example  of  others  incites  them  to  order  and  obedience. 

Naturally  there  must  be  proper  separation  of  patients  according  to  edu- 
cation and  mental  peculiarities,  as  is  carried  out  in  every  institution. 

However,  it  is  not  every  patient  that  requires  admission  to  an  asylum. 
As  long  as  the  public  regards  insanity  as  a  disgrace  and  sojourn  in  an  institu- 
tion has  a  detrimental  effect  in  the  eyes  of  the  world  upon  the  recovered 
patient,  commitment  to  an  institution  for  the  insane  should  be  carried  out 
only  after  mature  consideration  of  the  necessity.  Besides,  there  are  not 
enough  asylums  to  accommodate  all  the  insane. 

The  fundamental  principle  upon  which  the  decision  should  de- 
pend whether  admission  to  the  asylum  be  necessary  is  the  possibility 
of  cure.  If  the  conditions  at  home  be  unfavorable  or  are  the  cause  of 
the  disease;  if  the  physician  be  inexperienced  and  other  circum- 
stances be  unfavorable  for  mental  treatment;  or  if  means  be  limited, 
then  the  asjdum  is  necessary. 


^According  to  Jensen  ("Irrenfreund,"  1877,  99),  in  Allenbcrg,  of  1.5Ö  pa- 
tients of  commercial  occupations,  only  IG.l  per  cent,  recover,  while,  of  206 
domestics,  56.2  per  cent,  recover.  The  former  were  admitted  to  the  horrible 
asylum  only  after  all  other  means  had  been  exhausted,  while  the  latter,  since 
they  had  neither  money  nor  home,  were  admitted  at  once. 


254  GENERAL  PATTIOLOGV  AND  TIlERArY  OF  INSANITY. 

If  the  conditions  are  favorable,  then  the  asylum  becomes  \m- 
necessary;  but  at  least  it  seems  always  best  to  remove  the  patient 
from  his  ordinary  surroundings. 

A  second  point  is  the  danger  of  the  patient  for  himself  and 
others.  Watching  under  circumstances  of  private  care  does  not  suf- 
ficiently protect  against  accidents. 

A  third  point  is  the  resistance  of  the  patient  to  care,  the  impos- 
sibility of  carrying  out  a  course  of  treatment,  and  tlie  refusal  of  food. 

Finally,  much  depends  upon  the  nature  of  the  disiMsc  il.-^elf.  'i'\\v  institu- 
tion for  the  insane  should  be  used  only  for  ilnonic  cases.  The  lare.  adminis- 
tration, and  organization  of  an  a.sylum  are  unnecessary  for  eases  of  insanity 
that  run  their  course  in  a  few  days  or  weeks.  In  such  cases,  if  care  at  home 
is  not  sufficient,  care  in  an  ordinary  hospital  suffices.  Every  city  sliould  have 
a  hospital  arranged  for  the  reception  of  acute  cases  (delirium  tremens,  epi- 
leptic delirium,  etc.).  Among  chronic  cases  that  should  be  received  only  in  an 
asylum  for  the  insane  are  to  be  enumerated: — 

■  Melancholies  with  pronounced  twdiuni  rit(r  or  destructive  impulses  and 
those  who  refuse  food,  on  account  of  the  impossibility  of  overcoming  in  private 
treatment  the  consequent  dangers. 

Maniacal  and  furious  patients  require  an  institution  on  account  of  the 
isolation  they  need  and  their  dangerousness;  and  the  same  is  true  of  epilep- 
tics subject  to  frequent  outbreaks  of  excitement,  of  paranoiacs  who  have 
dangerous  delusions,  and  paralytics  in  the  initial  stages  of  their  malady. 
Commitment  to  an  institution  in  the  cases  of  hypochondriac  and  hysteric 
trouble  and  also  in  cases  of  reasoning  insanity  is  to  be  avoided  as  far  as 
possible,  especially  when  they  are  tainted,  irritable,  suspicious,  and  subject  to 
prejudice  and  ideas  of  persecution.  Quiet  secondary  dements,  and  paralytics 
in  the  final  stages  of  their  disease,  as  well  as  drunkards  and  the  criminal  in- 
sane, have  no  place  in  an  asylum. 

Admission  to  an  institution  for  the  insane  is  safeguarded  by  legal  meas- 
ures, which  must  be  fulfilled  in  order  to  prevent  the  misuse  of  the  institution, 
and  especially  to  guard  normal  individuals  from  unjustifiable  conunitment. 
It  is  sufficient  if  an  official  physician  certifies  to  the  existence  of  the  di.sease 
and  the  necessity  for  commitment,  and  that  finally  the  admission  of  the  pa- 
tient be  brought  to  the  knowledge  of  the  asylum  authorities,  as  well  as  to  the 
proper  judicial  authorities.  If  the  conditions  of  admission  be  made  too 
difficult,  then  the  utilitj'  of  the  institution,  which  already  has  so  many  preju- 
dices to  fight  against,  suffers  decidedly. 

If  commitment  be  necessary,  this  should  then  be  quietly  lold  to  tlic 
patient  openly,  and  he  should  not  be  deceived  ■\\itli  talk  about  making  a  busi- 
ness trip  or  visiting  a  watering-place  or  relatives.  In  the  most  favorable  case 
such  deception  keeps  the  patient  from  gaining  an  idea  of  his  real  position,  and 
frequently  enough  embitters  him  when,  discovering  the  deception,  he  awakes 
^\  ith  unfriendly  feelings  toward  the  institution  and  his  relatives. 


GENERAL  THERAPY.  255 

CHAPTER  V. 
Treatment  of  the  Fully  Developed  Disease. 

I.  Somatic  Therapy  by  Physical  and  Chemic  Meaxs. 

The  fundamental  principles  are:  (a)  Clear  uriderstanding  of 
the  origin  and  nature  of  the  physical  changes  lying  at  the  foundation 
of  insanity,  (b)  Avoidance  of  all  measures  that  may  weaken  the 
organism  of  the  insane  patient. 

The  notion  that  insane  patients  require  larger  doses  of  medicine  than 
normal  individuals  should  be  regarded  as  an  old  prejudice.  It  is  only  in  rare 
cases,  and  especially  with  reference  to  narcotics,  tliat  the  same  dose  has  a 
different  effect  in  the  same  patient  when  he  is  quiet  or  in  an  excited  state. 
Besides,  the  greater  tolerance  is  only  apparent,  since  the  patient  does  not  show 
or  notice  the  impleasant  effect  of  the  medicine;  he  does  not,  however,  react 
differently  to  the  medicine  than  a  healthy  person. 

With  reference  to  extracerebral  diseases,  conditions  so  important  etio- 
logically  and  therapeutically,  the  general  pathology  and  therapy  of  physical 
diseases  must  be  consulted.  He  who  would  understand  and  treat  mental  cases 
must  have  the  whole  of  medical  knowledge  at  his  command.  The  diagnostic 
and  therapeutic  difficulties  that  must  here  be  met  are  scarcely  less  than  in 
diseases  of  children.  Thorough  knowledge  of  neuropathology  and  gynecology 
is  especially  valuable;  medical  interference  in  the  latter  sense  must,  however, 
be  undertaken  with  foresight  and  tact.  Very  properly,  Ripping  warns  against 
too  much  interference,  and  Schule  against  reckless  interference.  In  general, 
exploratory  or  therapeutic  measures  are  to  be  undertaken  only  Avhen  the 
patients  have  sufficient  insight  into  their  condition,  or  where  interference  is 
demanded  on  account  of  danger  to  life  or  health  (hemorrhages,  profuse  dis- 
charges). 

The  remedies  at  hand  for  directly  treating  psychopathic  condi- 
tions are  few.    The  principal  thing  is  to  obtain  correct  indications. 

1.  Means  to  Prevent  the  Fluxion  of  Blood  to  the  Brain. 
(a)  By  Diminislt.mg  the  Quantity  of  Blood — Bleeding. 

Formerly  bleeding  was  much  abused  on  the  theory  a  priori  that 
insanity  depended  upon  inflammation. 

The  time  is  long  past  when  a  state  of  cerebral  irritation  was  regarded 
only  as  a  hyperemia  or  inflammation  of  the  brain,  and  resort  was  had  immedi- 
ately to  the  lancet  when  mania  was  diagnosticated  or  a  fever  was  attended 
by  delirium.  The  fact  that  insanity  not  infrequently  occurs  directly  after 
loss  of  blood,  or  arises  out  of  a  state  of  inanition,  caused  care  to  be  exercised 
in  the  application  of  bleeding. 

To-day  the  use  of  venesection  in  insane  patients  is  practically  proscribed; 
and  a  thousand  facts  of  experience^ — Avhich  show  that,  after  bleeding  of  melan- 
cholies and  maniacs,  increase  of  excitement  or  states  of  stuporous  exhaustion 


?:,r;       c?:xeral  PAriioi.dcN    wn  i  iikkapv  of  txsantty. 

followed,  and  that  scarcely  a  single  case  was  improved — justify  this  proscrip- 
tion. The  more  favorable  results  of  psychiatry  to-day  rest,  at  any  rate,  less 
upon  the  discovery  and  application  of  new  remedies  than  upon  the  abandon- 
ment of  weakening  measures,  among  whicli,  next  to  purgatives,  are  to  be  men- 
tioned tartar  emetic,  blisters,  moxas,  vesicatory  salves,  and  general  bleedings. 

As  a  rule,  insanit}'  arises  out  of  weakening  influences,  with  pro- 
gressive loss  of  body-weight,  and  leads,  as  a  result  of  intensified  brain 
activity,  to  sleeplessness  and  insufficient  nutrition,  to  inanition  and 
poverty  of  the  blood,  the  clear  expression  of  which  is  mental  ex- 
haustion, which  usually  follows  states  of  severe  mental  excitement. 

To  be  sure,  we  frequently  have  in  the  insane  manifestations  of 
cerebral  hyperemia;  tliis  is  not  the  result  of  plethora,  but  of  weak- 
ness— neuroparalytic  condition  of  the  vasomotor  nerves. 

It  is  here  evident  that  the  transitory  depletion  due  to  venesec- 
tion is  practically  worthless  when  the  impoverishment  of  the  blood 
thus  induced  can  be  overcome  only  slowly  or  not  at  all;  and  thus 
brings  the  danger  of  a  transformation  of  a  state  of  brain  exhaustion, 
reparable  in  itself,  into  a  condition  of  brain  atrophy.  In  those  rare 
cases  in  which  the  circumstances  make  bleeding  seem  necessary,  as 
in  the  beginning  of  acute  delirimn,  in  insanity  due  to  suppression  of 
the  menses,  or  in  certain  cases  of  climacteric  insanity,  leeches  applied 
behind  the  ear  or  to  the  mucous  membrane  of  the  nose,  or  cups  ap- 
plied to  the  back  of  the  neck  meet  the  symptomatic  indication.  In 
general,  we  have  every  reason  to  treat  the  insane  very  cautiously  by 
means  of  venesection. 

(h)   To  Diminish  the  AcUvily  of  the  Heart. 

For  this,  digitalis  should  first  be  mentioned  (in  the  form  of  the 
inf^^sion  or  tincture).  Its  cumulative  effect  calls  for  care  in  its 
administration.  Acute  catarrhal  affections  of  the  stomach  and  states 
of  intense  sexual  excitement  contra-indicate  its  continued  use  in 
large  doses.  Sodium  nitrate,  small  doses  of  morphine,  and  laurel- 
water  aid  the  effect  of  digitalis.  Cold  compresses  applied  over  the 
heart  quiet  the  heart's  action,  as  do  also  cold  wet  sheets  and  the 
reduction  of  temperature  by  cool  baths  (21°  to  16°  E.,  80°  to  68°  F.). 

(c)  By  Dilating  the  Peripheral  Vessels. 

This  method  is  especially  appropriate  for  continued  hyperemias 
(especially  venous)  of  the  brain.  Besides  lukewarm  baths,  rubbing 
with  damp  sheets,  wet  packs,  and  wet  bandages  to  the  legs  are  useful. 
The  indication  may  also  be  met  by  the  action  of  salines,  mineral 


CENTRAL  'rillCltAI'Y.  257 

waters  containing  Cllanl)or"s  salts,  Car]sl)ad  salts,  aloos,  rlniljarl),  and 
cascara.  Abundaiit  dcplciion  tlirougli  the  skin  inay  be  ellccted  by 
dry  cups. 

(d)  By  Contracting  ili,e  Cerebral  Vessels. 

Hydeothekapy.- — Contraction  of  the  cerebral  vessels  may  be 
obtained  reflexly  by  cold  compresses  or  ice-packs  applied  directly  to 
the  head  or  along  the.  vessels  of  the  neck. 

Ikkitation  of  the  Skin. — Heidenhain,  by  sensory  irritation  of 
the  skin,  obtained  contraction  of  all  the  vessels  of  the  body  reflexly 
through  the  vascular  center  in  the  medulla  oblongata.  Schiiller,  by 
means  of  sinapisms,  induced  at  first  dilatation  and  then  lasting  con- 
traction of  the  vessels  of  the  pia  mater.  This  way  of  limiting  the 
flow  of  blood  to  the  brain  is  especially  suitable  for  overcoming  venous 
hyperemia,  the  more  since  it  accelerates  the  circulation  at  the  same 
time,  and  thus  facilitates  the  removal  of  waste-products  and  increases 
oxidation  in  the  cerebral  tissue.  For  this,  perhaps,  general  mustard- 
baths  or  mustard  foot-baths  recommend  themselves,  and  also  large 
sinapisms  to  the  surface  of  the  body. 

Deugs. — The  effect  to  contract  the  blood-vessels  is  ascribed  to 
nicotine,  hyoscyamus,  nux  vomica,  belladonna,  quinine,'  lead,  caffeine, 
bromides,  opium,  and  morphine  in  small  doses,  as  well  as  to  ergot  and 
its  preparations. 

Of  all  these  remedies  ergot,  in  infusion,  or  better  in  the  form  of 
the  aqueous  extract,  and  ergotine  prepared  in  the  manner  of  Bonjean, 
Wernich,  or  Bombelon,  which  may  be  employed  subcutane ously,  is 
the  most  useful. 

Congestive  states  of  excitement  (simple  mania,  grave  mania, 
mania  of  paralytics,  certain  stages  of  acute  delirium,  transitory 
mania)  indicate  the  use  of  ergotine.  Schröder  Van  der  Kolk  and 
Van  Andel  employed  it  to  meet  such  indications.  Sclilangenhausen 
observed  relatively  good  results  in  states  of  excitement  of  menstrual 
origin.  He  gave  the  aqueous  extract  up  to  0.5  or  1.0  gram  a  day. 
The  dose  of  ergotine  (Bonjean,  Wernich)  subcutaneously  is  about 
the  same,  once  or  twice  daily. 

2.  Means  of  Inceeasing  the  Flow  of  Blood  to  the  Beain. 
(a)  By  Increasing  the  Hearfs  Action. 

Alcohol  and  analeptics  have  this  direct  effect.  Since  alcoholics 
at  the  same  time  increase  the  nutrition  of  the  brain  and  promote 
sleep,  and  also  retard  retrograde  metabolism,  they  find  properly  wide 


258  CEXERAL  PArilnl.OCY  AND  TTIERAFY  OF  INSANITY. 

application  in  functional  states  of  mental  weakness  and  states  of 
exhaustion. 

In  ordinary  cases,  and  when  continued  increase  in  the  flow  of 
blood  to  the  brain  is  necessary,  good  old  wine,  beer,  and  warm  alco- 
holic drinks,  like  grog  and  punch,  are  efficient.  When  the  heart's 
action  is  weak  and  the  circulation  depressed,  tea,  coffee,  brandy 
with  eggs,  and  etl\yl  alcohol  are  useful.  In  collapse  and  threatened 
syncope  subcutaneous  injection  of  sulphuric  ether  or  camphor  (1  to 
10  of  olive-oil)  have  an  excellent  effect. 

(h)  By  Dilating  the  Blood-vessels. 

Hydrotherapy. — Warm  applications  to  the  head  in  caps  filled 
with  warm  water,  cold  brief  rubbings,  rain-baths  for  fifteen  to  forty- 
five  seconds;  cool  half -baths  with  forced  douches  for  from  four  to 
five  minutes.    (Winternitz.) 

Drugs. — A  dilating  effect  on  the  vessels  is  attributed  to  ether, 
opium,  and  morphine  in  small  doses,  but  especially  to  amyl  nitrite, 
which  at  the  same  time  has  a  powerful  exciting  influence  on  the 
heart's  action.    It  is  effectual  only  in  inhalation,  not  by  the  stomach. 

(c)  By  Facilitating  tJie  Flow  of  Blood  to  the  Brain. 

This  indication  is  most  simply  fulfilled  by  rest  in  bed  with  the 
head  low — an  excellent  means  in  all  conditions  depending  upon 
inanition,  which  brings  quiet  often  more  quickly  than  narcotics.  In 
agitated  and  anxious  patients  the  fulfillment  of  this  indication  with- 
out restraint  is  difficult.  With  patience,  however,  the  object  is  often 
attained,  and  the  patient  becomes  quiet  and  obedient.  An  iron  bed- 
stead withotit  pillows  facilitates  the  attainment  of  this  object. 

3.  Means  of  Calming  Excitement  and  Excitability. 

(a)   General  Calmatives. 

1.  Narcotics. 

Narcotics  very  properly  play  an  ünportant  part  in  the  therapy 
of  the  psychoses,  in  that  they  overcome  mental  excitement  and 
hyperesthesia  and  induce  sleep. 

Opium. — Of  these  remedies,  opium  in  its  various  forms  (opium, 
laudanum,  aqueous  extract  of  opium)  is  one  of  the  most  important. 

The  best  form  of  administration  is  to  give  the  aqueous  extract  subcu- 
taneously  (1  to  20),  and  also  in  the  form  of  suppository. 

The  internal  administration  is  less  to  be  commended,  but,  when  it  be- 
comes necessary,  the  aqueous  extract  of  opium  should  be  given  with  tonics  or 
Spanish  wine. 


GENERAL  THERAPY.  259 

The  effects  of  opium  arc:  — 

1.  Quieting  and  diminishing  mental  hyperesthesia  and  precordial  disi/rcss. 
In  this  way  it  often  at  the  same  time  lias  an  hypnotic  influence. 

2.  It  stimulates  tlie  vasomotcjr  nerves,  and  thus  induces  vascular  con- 
traction. 

3.  It  has  a  trophic  effect  on  ihe  central  nervous  system  and  improves 
nutrition. 

Its  effect  to  cause  constipation  and  lessen  secretions  disappears  with 
continued  use.  Its  power  to  paralyze  the  heart  and  induce  venous  hyperemia 
of  the  brain  and  lungs  is  seen  in  poisoning  with  suicidal  Intent,  Vjut  this  is 
never  observed  after  ordinary  therapeutic  doses.  • 

No  injurious  effects  of  treatment  by  opiimi  in  the  insane  are  observed 
when  there  are  indications  for  it.  Even  fluxionary  cerebral  states,  if  they  be 
of  a  neuroparalytic  nature,  do  not  contra-indicate  the  use  of  opium.  On  the 
other  hand,  it  is  injiu'ious  in  all  conditions  of  venous  hyperemia. 

Anemic,  hysteric,  and  hypochondriac  patients  react  with  special  intensity 
to  opiates,  but  there  is  seldom  such  an  idiosj'ncrasy  that  the  treatment  must 
be  suspended. 

As  a  local  effect  of  the  subcutaneous  use  of  opium,  abscesses  are  not  in- 
frequent, but  they  heal  with  surprising  rapidity  (local  trophic  effects  of 
opium  ? ) . 

Opiimi  in  cases  of  initial  melancholia  is  of  inestimable  worth.  In  such 
cases  it  has  a  direct  effect  to  overcome  mental  hyperesthesia,  and  it  is  espe- 
cially useful  when  there  are  imperative  ideas  and  precordial  distress.  Too,  at 
the  height  of  melancholia,  if  it  be  active,  with  violent  precordial  distress, 
opium  is  a  direct  curative  remedy. 

Its  effect  in  the  acute  alcoholic  psychoses  (melancholia,  mania,  insanity 
of  persecution)  and  delirium  tremens  is  excellent;  and  finally  it  is  useful  in 
cases  where  mania  is  diminishing  and  mental  hyperesthesia  is  still  present, 
and  also  in  cases  of  irritable  furious  mania  accompanied  by  angry  outbreaks. 

In  all  other  forms  of  mania,  as  well  as  in  passive  melancholia,  it  seems  to 
be  without  effect,  if  not  actually  injurious. 

Opium  may  be  administered  internally  and  subcutaneously.  For  internal 
use,  powdered  opium,  laudanum,  and  the  aqueous  extract  are  appropriate,  but 
for  subcutaneous  administration  only  the  latter  is  to  be  recommended. 

The  solution  of  the  aqueous  extract  is  much  more  stable  if  a  small 
amount  of  glycerin  is  added.  This  is  also  true  of  solutions  of  morphine.  Too, 
the  solution  should  be  reneAved  often  and  frequently  filtered.  With  these  pre- 
cautions, abscesses  at  the  seat  of  injection  need  scarcely  be  considered.  The 
injection  is  rather  painful.  The  quieting  and  anesthetic  mental  effect  of 
opium  is  obtained  as  soon  as  average  doses  of  from  0.1  to  0.2  gram,  twice 
daily,  are  attained.  Ordinarily  this  is  sufficient.  Sometimes,  however,  the 
dose  must  be  increased  to  0.5  gram  twice  daily,  \^^len  the  height  of  the  dis- 
ease has  been  passed,  the  dose  should  be  gradually  diminished.  It  administra- 
tion should  never  be  suddenly  interrupted.  It  is  easy  to  overcome  the  habit 
that  has  been  established.  Manifestations  like  those  of  morphinism  are  never 
observed;  at  most,  nothing  more  than  lassitude  and  mental  inertia.  Minimum 
and  widely  separated  doses  are  useless  in  the  treatment  with  opium.  The 
initial  dose  sliovüd  be  0.03  gram,  twice  daily,  and  it  should  be  increased  as 
rapidly  as  possible. 


?60  CENRRAL  PATHOLOGY  AND  TIIEKAPY  OF  TNSAM  TV. 

jMokthine. — Morphine  in  general  has  the  effect  of  opium,  hut 
not  its  trophic  influence;  so  that  in  all  cases  Avhere  choice  can  be 
made  between  the  two,  and  the  state  of  nutrition  is  much  reduced, 
opium  shonld  be  given  the  preference.  The  vasomotor  and  quieting 
effect  of  morphine  is  greater  than  that  of  opium. 

Small  doses  (0.01  to  0.03  pram  suhcvitancously)  have  a  stiiiuilatiiig  effei-t 
upon  the  vessels;  large  doses  {0.03  to  O.O.l  gram)  caus6  vascular  paralysis.  A 
local  and  general  sedative  effect  is  obtained  by  doses  of  from  0.01  to  0.1  gram. 
We  use  exclusively  solutions  of  1  part  of  morphine  or  opium  extract  in  13 
parts  of  distilled  Avater  and  2  parts  of  glycerin. 

At  the  beginning  of  treatment  the  enietic  effect  of  tlie  drug  is  disturb- 
ing. This  is  easily  overcome  by  rest  in  the  horizontal  position,  black  coffee, 
and  the  addition  of  a  small  amoimt  of  atropine. 

Unpleasant  accidents  sometimes  occur  in  its  subcutaneous  administra- 
tion, either  immediately  after  the  injection  or  one  or  tAvo  hours  later.  In  the 
first  instance,  the  accident  is  not  dependent  upon  the  dose  and  not  upon  its 
injection  into  a  vein,  but  probably  upon  mechanical  or  chemic  irritation  of  a 
cutaneous  nerve  (acid  fermentation  of  the  solution),  and  reflex  paralysis  of 
the  nerve-centers  of  the  medulla  (arrest  of  the  heart's  action  and  respiration). 
There  may  be  instantaneous  paralysis  of  the  vessels  of  the  skin  at  the  point 
of  injection  which  rapidly  spreads  (erythema  and  sensation  of  burning)  and 
may  precede  the  attack,  or  it  may  go  no  further  (vasomotor  paralysis).  In 
such  cases  artificial  respiration  and  stimulation  are  necessary,  such  as  electric 
stimulation  of  the  phrenic  nerves. 

In  the  second  instance  there  is  possibility  of  actual  intoxication  Avliich 
must  be  treated  with  injections  of  atropine,  artificial  respiration,  stimulation, 
and  possibly  even  venesection. 

Morphine  never  has  a  cumulative  effect.  Its  effect  passes  off  in  a  few 
lioiu's.  After  it  has  been  used  in  large  doses  for  months,  it  becomes  a  neces- 
sity to  the  central  nervous  system.  Out  of  this  develops  so-called  morphinism 
(L-ide  "Special  Pathology"). 

The  subcutaneous  administration  of  morphine  is  that  most  used  and  the 
best  in  psychoses.     It  has  the  following  indications: — 

1.  In  melancholic  states  with  neuralgic  or  vasoparetic  symptoms  on  ac- 
count of  its  local  and  general  sedative  effect  "with  vascular  stimulation. 

2.  In  paranoia  with  hyperesthesia  and  neuralgic  sensations,  with  delu- 
sions dependent  upon  them  (delusions  of  physical  persecution) ;  in  hallucina- 
tions with  hyperesthesia  of  the  acoustic  centers,  and  especially  in  halluci- 
natory paranoia. 

3.  In  irritable  mania,  and  in  cases  of  mania  where  the  excitement  is 
diminishing  and  in  which  great  irritability  is  constantly  excited  by  external 
irritation,  as  a  result  of  which  relajises  are  induced  and  convalescence  pro- 
tracted. It  is  also  useful  in  the  angry  outbursts  of  imbeciles.  In  such  cases 
morphine  acts  by  reducing  the  increased  mental  excitability. 

4.  In  states  of  intercurrent  excitement  in  paralytics  that  are  accom- 
panied by  vascular  paralysis  (fluxionary,  maniacal).  In  such  cases  doses  that 
stimulate  the  vessels  are  appropriate  (0.03  gram). 

5.  In  states  of  intercurrent  excitement  of  chronic  insanity  which  are  due 
to  fluxions,  hallucinations,  and  emotional  states  it  has  a  calmative  effect. 


GENERAL  THERAPY.  201 

6.  In  periodically  recurring  maniacal  attacks  and  in  states  of  circular 
excitement  which  begin  with  prodromal  vasomotor  phenomena  (small,  tense, 
rapid  pulse).     In  such  cases  large  doses  are  necessary. 

Morphine  is  contra-indicated  in  marasmus,  tendency  to  collapse,  uncom- 
pensated valvular  lesions,  fatty  heart;  in  mania  at  its  height,  and  in  cases 
where  it  has  an  expansive  character. 

Alkaloids  of  opium,  such  as  narcoine,  introduced  ])y  Claude  Bernard,  and 
papaverine,  recommended  by  Leidesdorf  and  others,  may  Ije  dispensed  with ; 
besides  being  high  priced,  they  are  less  active  than  morphine. 

An  exception  may  be  made  in  the  case  of  codeine,  wliich,  according  to  our 
experiments,  may  often  replace  opium,  and  besides  has  the  advantage  that  it 
is  not  constipating  and  benumbing.  It  has  also  the  advantage  over  morphine 
that  it  does  not  induce  a  habit.  Its  narcotic  value  is  about  one-third  less  than 
that  of  morphine.  The  muriate  of  codeine  is  convenient  for  internal  use.  (in 
pills  or  in  mixture:  codeine  muriate,  U.3;  aq.  dest.,  130;  syr.  menth.,  20.0. 
One  teaspoonful  from  two  to  ten  times  daily.)  The  phosphate  of  codeine  may 
be  used  subcutaneously. 

Stramonium,  recommended  by  Michea,  conium,  hydrocyanic  acid,  and 
chloroform  have  not  com,e  up  to  expectation. 

After  opiates,  preparations  of  belladonna  are  decidedly  the  most  eflTectual. 
However,  "grave  melancholic  conditions  with  impulsive  states  of  anxiety 
sometimes  require  a  longer  continuance  of  treatment  with  the  extract  of 
belladonna"  (Schule).  Usually  opiates  are  simultaneously  administered,  and, 
according  to  my  experience,  in  appropriate  and  grave  cases  of  melancholia  the 
combination  of  opium  with  belladonna  has  shown  itself  to  be  very  useful. 

Bkomides. — The  bromides  are  among  the  most  important  reme- 
dies at  oiir  command  in  the  domain  of  nervons  therapentics.  Tlieir 
valne  is  due  to  their  effect  in  depressing  cerebral  activity,  especially 
the  reflex  excitability  of  the  central  nervons  system.  On  acconnt  of 
their  peculiar  effect  on  the  central  nervous  organs,  their  employment 
is  indicated  in  those  cases  which  present  abnormal  increased  ex- 
citability, especially  in  the  reflex  centers,  and  abnormal  excitement. 
The  bromides  are  specially  useful  in  psychoses  that  depend  upon 
irritation  in  some  oi'gan  (uterus),  and  that  are  to  be  regarded  as 
reflex. 

To  this  class  of  cases  specially  belong  constitutional  melancholia  with 
spinal  hyperesthesia,  and  forms  of  sexual  paranoia  during  or  unconnected 
with  the  climacteric,  as  well  as  persecutory  insanity  arising  out  of  sensations. 
Bromides  are  further  useful  in  periodic  insanity  with  irritation  of  the  genital 
nervous  system,  as  well  as  in  mania  with  sexual  excitement,  on  account  of 
their  anaphrodisiac  effect.  Finally  they  are  hypnotic  for  many  patients  in 
doses  of  from  4.0  to  6.0  grams.  Bromides  have  shown  themselves  to  possess 
especial  value  in  the  treatment  of  epilepsy,  and  not  merely  in  the  early  and 
reflex  cases,  but  also  in  the  chronic  and  idiopathic  cases. 

Piscidia  erythrina  as  a  sedative  seems  to  produce  an  effect  analogous  to 
that  of  the  bromides.  It  was  recommended  in  1844  by  Hamilton  as  an  hypnotic. 
Like   bromine,   this   drug    (vegetable    bromine)    seems    to    diminish   decidedly 


262         GENERAL  PATHOLOGY  AND  THERAPV  OF  INSANITY. 

mental  aud  cerebral  excitability  and  excitement.  The  dose  is  from  2  to  3 
teaspoonfuls  of  the  fluid  extract.  There  are  no  unpleasant  secondary  effects. 
Piscidia  is  easily  taken  in  water  with  a  little  syrup  of  peppermint.  I  luive 
found  its  oonibinatiun  with  bromides  especially  useful. 

Hyoscixe. — One  of  the  most  poweri'ul  calmative  remedies  we 
have  is  hyoscihe.  It  paralyzes  temporarily  the  cerebral  cortex.  It 
diminislies  innervation,  and  causes  titubation,  drawling  speech,  and 
sleepiness,  and  often  a  sleep  lasting  six  or  eight  hours. 

The  hydrochlorate  maj'  be  given  internally  up  to  0.003  gram,  and  sub- 
cutaneously  from  0.0005  to  0.001  gram  per  day.  Its  interrupted  iise  is  a 
benefit  to  patients  and  to  nurses,  since  patients  given  to  untidiness  and  de- 
structiveness  in  states  of  motor  excitement  are  quieted,  as  in  cases  of  periodic 
mania,  the  excited  states  of  epileptics  and  paralylies,  in  grave  alcoholic  uuiiiia, 
and  in  agitated  dementia. 

Since  hyoscine  interferes  with  nutrition,  in  all  curable  cases,  except 
where  it  is  necessary  to  transport  maniacal  patients,  it  is  not  to  be  recom- 
mended. Too,  in  incurable  cases  it  never  should  be  used  but  temporarily.  It 
is  contia-iiulicated  in  heart  disease. 

DuBOisiNE. — Sulphate  of  duboisine  introduced  into  psychiatric 
practice  by  Ostermayer,  is  superior  to  hyoscine  in  operation  and 
much  less  dangerous. 

It  is  a  powerful  sedative  and  also  frequently  has  an  hypnotic  effect.  Its 
indications  are  in  general  those  of  hyoscine.  It  has  little  effect  given  inter- 
nally. Subcutaneously  its  effect  is  observed  within  a  half-hour;  usually  a 
subcutaneous  dose  of  0.0008  to  0.001  gram  is  sufficient.  The  dose  sliould 
never  be  increased  beyond  0.002  gram.  Within  these  limits  the  pulse,  respira- 
tion, and  temperature  are  not  essentially  influenced.  It  seems  to  have  no 
cumulative  action. 

2.  Physical  and  Bicictic  Cainiatice  Bcnirdies. 

Besides  rest  in  bed,  occasional  or  temporary  isolation  of  the 
patient,  and  avoidance  of  irritation  of  the  senses,  certain  forms  of 
hydrotherapy  as  a  means  of  calming  patients  are  first  to  be  men- 
tioned. 

LuKEWAEM  FULL  BATHS  from  25°  to  27°  E.  (80°  to  90°  F.). 
These  baths  have  not  only  a  refreshing  effect  in  the  promotion  of 
physical  and  chemic  processes  of  the  body,  and  producing  a  derivative 
effect  by  dilatation  of  the  cutaneous  blood-vessels  and  aiding  absorp- 
tion— at  the  same  time  lowering  the  pulse  and  temperature — but 
they  have  also  a  quieting  effect  through  their  uniform  excitation  of 
the  cutaneous  nerves,  and  thus  they  often  induce  sleep. 

Ordinarily  they  are  prolonged  from  thirty  minutes  to  an  hour. 
If  fluxion  to  the  head  be  present,  cold  compresses  are  simultaneously 


GENERAL  THERAPY.  263 

applied  to  the  head.  This  treatment  has  been  extended  to  prolonged 
baths  of  about  28°  E.  (90°  ¥.),  introduced  by  Brierre,  and  continued 
for  ten,  twelve,  or  fourteen  hours.  During  the  bath  the  patient's 
head  is  douched  with  water  of  about  15°  E.  (65°  F.). 

Brierre  found  them  effective  in  the  initial  stages  of  mania  and 
melancholia,  especially  of  alcoholic  and  puerperal  origin.  They  are 
contra-indicated  in  anemia  and  in  general  in  states  of  exhaustion: 
Under  all  circumstances  their  use  must  be  combined  with  strengthen- 
ing diet. 

Douches,  rain-baths,  and  plunge-baths,  such  as  are  often  used  in 
hydropathic  institutes,  should  be  avoided  in  the  psychoses.  They 
reduce  temperature  too  much  and  excite;  and  douches  shock  mechan- 
ically and  are  therefore  injurious. 

A  very  good  calmative  and  often  hypnotic  measure  is  Priessnitz 
packs  of  from  one  to  several  hours'  ^  duration,  which  have  lately  been 
recommended. 

(dj  Hypnotics. 

Sleeplessness,  which  is  so  frequent  in  the  insane  and  has  such 
an  injurious  effect  both  ]3hysically  and  mentally,  is  difficult  to  treat. 
The  treatment  must  be  individualized  and  directed  to  the  removal 
of  the  cause  of  the  insomnia.  The  causes,  however,  are  very  numer- 
ous and  are  not  always  easily  discovered. 

In  many  patients  states  of  inanition  of  the  brain  and  cerebral 
anemia  are  the  causes  of  sleeplessness.  It  is  in  just  these  cases, 
however,  that  all  means  should  be  tried  to  produce  sleep.  Eest  in 
bed  with  abundant  food  at  the  evening  meal,  with  alcohol,  is  ef- 
fectual; strong  beer  or  good  old  wine,  hot  wine,  wine-punch,  and 
stronger  liquors  often  in  such  cases  have  the  desired  hypnotic  effect. 
If  these  more  or  less  dietetic  hypnotics  are  insufficient,  then  paralde- 
hyde or  chloral  may  be  tried.  In  states  of  grave  mental  exhaiistion 
injections  of  camphor  may  do  some  good. 

Morphine  and  opium  are,  for  the  most  part,  useless  with  very 
anemic  patients;  sometimes  in  such  cases  the  combination  of  these 
drugs  with  quinine  used  subcutaneously  is  successful.     The  author 


*  Svetlin  commends  the  value  of  packing  with  sheets  dipped  in  water  of 
from  18°  to  20°  R.  (72°  to  77°  F.)  (one  to  two  hours)  for  calming  the  excite- 
ment of  mania.  Even  in  periodic  mania  at  the  beginning  he  asserts  that  he 
has  cut  the  attack  short,  and  also  reduced  the  excitement  by  lowering  the 
temperature  and  pulse-rate.  The  hypnotic  effect,  which  is  never  wanting,  is 
especially  valuable.  Begin  with  applications  lasting  from  two  to  two  and  one- 
half  hours  and  continue  until  the  sleep  is  shorter  and  less  profound.  In  such 
case  the  duration  of  the  application  should  be  diminished. 


264         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

uses  0.25  gram  of  salts  of  morphine  in  5.0  grams  of  gl_ycei-in^  and  1.0 
gram  of  quinine  bisulphalo  in  15.0  grams  of  distilled  water.  The 
solution  is  mixed  and  iilteri'd.  An  ordinary  hypodermic  syringe  con- 
tains 0.0125  gram  of  morjihine  and  0.05  gram  of  quinine. 

Sleeplessness  dependent  upon  intoxication  usually  diminishes 
with  the  elimination  oL'  the  toxic  substance.  Antidotes  are  valuable, 
such  as  strychnine  in  alcoholism.  In  asthenic  states  with  sleepless- 
ness due  to  alcoholic  excesses  it  usually  yields  to  opium. 

It  is  more  difficult  to  choose  an  appropriate  hypnotic  in  the 
organic  psychoses  like  acute  delirium  and  dementia  paralytica,  in 
which  it  is  necessary  to  determine  whether  fluxions,  defect  of  the 
excretion  of  waste-products,  irritation  of  the  brain,  pain,  etc.,  prevent 
the  occurrence  of  sleep.  In  congestive  states  of  the  brain  lukewarm 
baths  with  application  of  compresses,  use  of  digitalis,  and  injections 
of  ergotine  are  appropriate.  When  there  is  cerebral  irritation,  small 
doses  of  morphine  are  valuable  (subcutaneously  0.01  to  0.015  gram). 

In  functional  psychoses  there  are  a  number  of  conditions,  partly 
mental,  partly  physical,  which  cause  sleeplessness. 

The  most  important  mental  causes  are  psychic  hyperesthesia; 
painful  ideas,  often  having  the  character  of  imperative  concepts; 
emotional  states,  especially  those  of  expectation.  In  such  cases 
remedies  which  have  the  effect  to  bring  mental  quiet  are  indicated: 
opium;  morphine,  especially  when  used  subcutaneously;  and  also 
sulphonal,  amyl  hydrate,  bromides,  and  piscidia.  This  treatment  has 
little  influence  to  overcome  delirium  and  hallucinations  when  these 
are  the  mental  cause  of  excitement. 

Important  physical  exciting  causes  are  neuralgias  and  paralgias, 
against  which  salicylic  acid,  salol,  antipyrin,  phenacetin,  salipyrin, 
exalgin,  and  morphine  subcutaneously  are  valuable;  other  causes  are 
palpitation,  feeling  of  pulsation  due  to  hyperesthesia  of  the  nerves 
distributed  to  the  vessels,  and  feelings  of  anxiety,  to  oppose  which 
lukewarm  baths,  Priessnitz  baths,  valerian,  laurel-water,  monobro- 
mate  of  camphor  in  suppositories,  bromides,  and  piscidia  are  useful. 
Excitement  in  the  sexual  sphere  is  also  frequently  a  cause  of  sleep- 
lessness. When  the  cause  is  mental  (increased  libido),  large  doses 
of  bromides  are  useful.  They  are  also  valuable  when  the  cause  is 
peripheral,  in  combination  with  cool  sitz-baths  and  anaphrodisiacs. 

Frequently  precise  indications  cannot  be  found,  and  the  only 
thing  that  can  be  done  is  to  employ  direct  narcotic  influence  upon 
the  cerebral  cortex.  The  value  of  the  various  means  at  hand — 
chloral  hydrate,  amyl  hydrate,  paraldehyde — is  not  very  uniform. 
Äfanv  arc  not  without  danger  when  used  for  any  length  of  time,  and 


GENEßAL  THERAPY.  265 

for  this  reason,  as  well  as  owing  to  the  fact  that  even  in  heroic  doses 
they  lose  their  effect,  it  is  necessary  to  change  frf!r(iu;ntly. 

The  sovereign  hypnotic  is  still  chloral  hydrate.  Wlien  used  temporarily 
its  effect  is  excellent.  It  is,  however,  a  cardiac  poison,  and  when  used  for  a 
long  time,  even  in  medicinal  doses  (3  grams),  induces  chronic  intoxication 
(vasoparesis,  anemia,  edema,  tendency  to  hemorrhage,  decubitus,  mental  dull- 
ness, etc.).  It  is  contra-indicated  in  fatty  heart  and  atheroma.  C'liloral 
hydrate  is  especially  useful  in  asthenic  cerebral  states  and  in  symptoms  of 
vascular  spasm  and  cerebral  anemia.  Infrequently,  however,  it  has  an  exciting 
effect.  The  addition  of  morphine  increases  the  effect  of  chloral.  A  medium 
dose  is  from  2  to  3  grams.  Doses  beyond  4  grams  are  dangerous,  and  may  in- 
duce death  by  cardiac  paralysis.  Chloral  hydrate  is  administered  internally  or 
by  enema.  Croton  or  butyl  chloral  seems  to  affect  the  heart  less,  but  it  is  in- 
ferior to  chloral  hydrate.  The  klcoholate  is  quite  like  chloral  hydrate  in  its 
effect,  and,  on  account  of  its  less  irritating  taste,  preferable.  The  latest 
chloral  preparations  (chloralamid,  chloralurethane,  etc.)  in  general  have  the 
advantages  and  disadvantages  of  chloral  hydrate  and  are  inferior  to  it.  Chloral 
ammonia  decomposes  quickly  and  cannot  be  used  in  practice. 

The  best  antidote  for  chloral  poisoning,  recommended  by  French  ob- 
servers {Annales  Medico-psycJiologiques,  1886,  July),  is  strychnine  administered 
subcutaneously.     Belladonna  is  also  said  to  be  useful. 

Paraldehyde  is  inferior  to  chloral  in  its  effect,  but  it  has  the  advantage 
that  in  medicinal  doses  (8  grams)  its  use  can  be  longer  continued  without 
diminishing  its  effect.  Too,  it  has  no  injurious  effect.  Infrequently  it  excites. 
Paraldehyde  is  a  very  valuable  hypnotic  in  states  of  inanition,  and  also  in 
psychoses  dependent  upon  hysteric  and  neiu-asthenic  conditions.  If  finally  its 
effect  begins  to  diminish,  augmentation  of  the  dose  seems  less  useful  than 
temporary  suspension  of  its  administration.  Its  unpleasant  smell  and  taste 
are  disturbing  to  the  patient,  and  other  patients  are  disturbed  by  the  odor  of 
the  patient's  breath. 

To  overcome  this  I  have  foimd  the  best  corrective  to  be  the  tincture  of 
orange.  The  mixtiu-e  can  be  taken  quite  readily  in  sweetQued  water.  Its  ad- 
ministration in  water  by  enema  is  also  convenient.  Since  this  drug  has  no 
depressing  effect  upon  the  heart,  it  may  be  given  when  there  is  fatty  heart, 
valvular  lesions,  etc.  Gastric  disturbance  is  no  obstacle,  since  it  does  not  dis- 
turb digestion  and  the  appetite  is  not  interfered  with.  iSleep  induced  by 
paraldehyde  is  like  natural  sleep,  and  lasts  from  four  to  six  hours. 

Amyl  hydrate  stands  between  chloral  and  paraldehyde.     The  dose  is  from. 
4  to  6  grams,  and  the  best  adjuvant  is  cognac. 

Trional  and  sulplwnal  are  the  best  two  hypnotics  of  the  present  time,  • 
because  they  do  not  injuriously  affect  the  circulation,  both  belonging  to  the 
group  of  the  disulphones.  Trional  has  partially  displaced  sulphonal,  since  it 
breaks  up  more  easily  and  is  more  rapidly  excreted.  It  has  a  more  certain 
and  rapid  effect  than  sulphonal  and  fewer  unpleasant  results,  such  as  numb- 
ness and  disturbance  of  equilibrium,  and  given  in  proper  doses  shows  no  un- 
toward symptoms  or  toxic  manifestations  like  those  which  have  been  observed, 
from  sulphonal.  It  is  advisable  not  to  give  trional  continuously,  and  to 
promote  diuresis,  using  milk  and  carbonated  waters.  As  a  dose.  1  to  1.5 
grams  is  sufficient,  and  it  is  best  administered  in  toddy,  warm  lemonade,  or 


26G         GENERAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

floated  on  beer.  I  generally  give  it  every  other  evening,  since  it  usually  exerts 
some  influence  the  second  evening  after  administration,  and  I  never  give  more 
than  1.5  grams.  On  the  evening  when  no  trional  is  given  one  can  give  to  ad- 
vantage 2  grams  of  potassium  bromide  with  0.5  gram  of  phenacctiii  and  0.03 
gram  of  codeine. 

Indeed,  trional  is  the  best  hypnotic  for  the  insomnia  of  melancholia, 
delusional  insanity,  mild  forms  of  mania,  neurasthenic  conditions,  and  chorea. 
In  insomnia  resulting  from  pain  it  is  of  little  value.  HoAvever,  its  effect  is 
also  here  manifested  if  combined  with  small  doses  of  codeine  or  morphine. 
Further  I  have  learned  to  value  trional  as  an  agent  to  quiet  mental  excite- 
ment, for  which  it  is  best  given  in  broken  doses — 0.5  gram  several  times  daily. 

The  hypnotic  effects  of  opium,  morphine,  and  hyoscine  have  already  been 
mentioned.  Cannabis  I  regard  as  useless  in  the  psychoses,  even  in  doses  of  0.5 
gram  and  more.  Cannabinon  is  a  doubtful  and  not  harmless  remedy.  Urethanc, 
even  in  doses  up  to  0.04  gram,  has  scarcely  given  any  result  in  my  observation. 

Bromides  and  piseidia  are  not  direct  hypnotics,  but  indirect,  in  that  they 
overcome  mental  and  sensory  hj'peresthesia,  and  tlius  remove  mental  and 
physical  irritation  which  interferes  with  sleep. 

Before  resorting  to  heroic  use  of  hypnotics  other  physical  calm- 
ative means  should  he  tried  (lukewarm  baths,  Priessnitz  packs,  com- 
presses to  the  calves,  galvanic  currents  to  the  head).  Cases  of  mild 
insomnia  may  he  overcome  by  cold  infusions  of  valerian,  or  valerian- 
ate of  quinine  (0.1  gram). 

(c)  AnapJirodisiacs. 

In  mental  disease  excitement  in  the  sexual  sphere  is  a  frequent 
and  troublesome  symptom,  often  attended  by  onanism.  As  a  rule, 
the  sexual  excitement  is  central.  Materia  medica  contains  numerous 
anaphrodisiacs,  but  their  effect  is,  in  general,  slight. 

Of  those  that  may  be  emploj^ed,  we  may  mention  the  bromides 
first,  and  then  belladonna,  lupulin,  camphor,  and  tincture  ofTvera^" 
trum  viride.  Salicylic  acid  seems  to  have  the  eifect  to  diminish 
sexual  excitement  after  long-continued  administration.  Sodium 
nitrate,  lately  recommended  by  Hammond  in  doses  from  2  to  -i  grams, 
is  not  without  value,  especially  in  psychic  sexual  hyperesthesia  (ere- 
thismus  sexualis). 

Masturbation  is  an  unpleasant  complication,  and  it  demands  considera- 
tion. Very  little  can  be  accomplished  with  medicines  alone.  Sometimes, 
especially  in  women,  it  is  caused  by  peripheral  irritation  caused  by  oxyuris, 
vaginismus,  leucorrhea,  or  pruiitus.  Along  with  local  treatment,  in  which 
applications  of  cocaine  are  not  without  value,  suppositories  of  the  drugs  men- 
tioned are   of   some   assistance.     In   general,   dietetic  measures    (cold   sponge 

p.-    rubbings,  sitz-baths,  physical  fatigue,  avoidance  of  highly  seasoned  food  ajid 

strong  wines),  careful  watching,  and  proper  mental  treatment  are  the  best. 


"^Z 


GENERAL  THERAPY.  2C7 


4.  Tonics. 


In  the  psychoses  there  are  various  indications  arising  out  of 
causal  and  complicating  bodily  weakness  and  poverty  of  the  blood. 
The  principal  remedies  in  such  conditions  are  good  food,  good  wines, 
and  fresh  air,  together  with  certain  physical  applications.  Of  the 
latter,  the  most  important  are  hydrotherapy  and  general  faradization, 
the  latter  first  introduced  by  Beard  and  Eockwell. 

In  hydrotherapeutic  measures  a  tonic  efi'ect  is  obtained  by  the 
use  of  cold  water, — that  is,  temporary  impressions  made  by  water  of 
rather  low  temperature  thrown  with  great  mechanical  force  in  the 
form  of  rain-baths  of  from  thirty  to  forty-five  seconds'  duration; 
cool  half-baths  of  from  24°  to  20°  E.  (86°  to  77°  F.),  with  forcible 
douching  and  I'ubbing  of  four  or  five  minutes'  duration,  and  rinsing 
with  water  of  from  20°  to  12°  R.  (77°  to  60°  F.),  followed  by  brisk 
rubbing;  and,  finally,  rubbings  Avith  wet  sheets  at  from  23°  to  16°  E. 
(84°  to  70°  F.).  Even  in  conditions  of  inanition  and  anemia  with  sub- 
normal temperature  the  latter  treatment  may  be  used  if  it  be  applied 
after  the  patient  has  been  enveloped  for  a  quarter  or  a  half -hour  in 
a  woolen  blanket;  then  only  the  superfluous  heat  is  removed. 

General  faradization  is  to  be  recommended  as  a  tonic  of  the 
greatest  value.  It  is  not  painful  when  it  is  properly  employed,  and 
it  may  be  applied  to  patients  confined  to  bed.  A  bath  filled  with 
warm  water  provided  with  a  binding  post  to  which  the  negative  pole 
of  the  apparatus  is  attached  may  be  ajDplied  to  the  feet,  and  proves 
very  practical. 

There  are  also  important  indications  for  quinine  and  iron,  and 
not  less  for  the  tonic  effect  of  ergotine,  as  well  as  for  nux  vomica, 
which  was  recommended  in  1867  by  0.  Müller. 

5.  Diet. 

One  of  the  first  conditions  favorable  to  recovery  is  the  careful 
nutrition  of  the  patient,  which  should  be  controlled  by  weighing  the 
patient  at  intervals.  Insomnia  and  excessive  muscular  exercise  re- 
duce the  vitality  of  many  patients.  With  this  occur  central  and 
trophic  disturbances,  and  interference'  with  assimilative  processes, 
which  impair  the  function  of  the  ganglion-cells  and  engender  a 
prolonged  period  of  exhaustion  with  imperfect  recovery  and  final 
atrophy.  A  mixed  diet  with  only  a  moderate  amount  of  fat  is  suit- 
able for  most  chronic  forms  of  insanity.  In  acute  cases  rich  milk  and 
eggs  are  best,  especially  in  those  cases  showing  mental  excitement 
and  anxiety.     A  full  meat  diet  is  contra-indicated,  since  it  causes 


268         GENERAL  PATHOLOGY  AND  THEEAPY  OF  INSANITY. 

excitement,  and,  the  digestion  being  enfeebled,  there  is  an  exces- 
sive production  of  elements  of  decomposition,  which,  being  absorbed, 
irritate  ihc  nerves,  disturb  sleep,  and  locally  affect  the  intestinal 
tract.    The  white  meats,  mutton,  and  fish  are  the  least  iujurious. 

An  excellent  article  for  dietetic  treatment  is  somatose,  which 
consists  of  SSiS  per  cent,  albumin,  7.5  per  cent,  salts,  and  0.25 
per  cent,  peptone.  I  give  about  V„  ounce  of  it  daily  in  divided  doses, 
administering  it  in  milk  or  soup.  It  usually  increases  the  weight  and 
improves  the  appetite  within  a  short  time. 

Fresh  air  and  scrupulous  cleanliness  are  further  requirements 
of  treatment,  and  the  whole  mode  of  living  must  be  regulated,  which 
can  be  best  accomplished  in  an  institution  through  careful  discipline. 
The  majority  of  patients,  especially  the  anemic,  require  considerable 
warmth. 

For  many  patients  rest  in  bed  is  an  important  therapeutic  re- 
quirement. In  all  psychoses  with  evidence  of  cerebral  anemia  and 
marasmus,  and  in  all  cases  when  nourishment  is  refused,  it  is  neces- 
sary, and  it  quiets  and  has  a  strengthening  effect  by  facilitating  the 
flow  of  blood  to  the  brain,  as  well  as  by  lessening  muscular  Avork  and 
diminishing  loss  of  heat. 

The  fulfillment  of  these  hygiemc  indications  /of  cleanliness,  of 
sufficient  warmth,  of  quiet  and  ample  nourishment,  is  often  pos- 
sible onl}^  with  great  difficulty,  owing  to  the  condition  and  actions  of 
the  patient. 

Many  patients  are  very  unclean.  This  obstacle  to  hygiene  re- 
quires that  they  be  treated  ^  individually.  At  the  height  of  states  of 
excitement  very  little  can  be  done.  We  must  be  satisfied  to  place 
such  patients  in  a  part  of  the  hospital  which  affords  fresh  air,  plenty 
of  heat  and  water,  cemented  walls  and  waterproof  floors,  with  beds 
having  mattresses  made  in  three  parts;  and  they  must  be  kept  in 
such  a  place  during  the  continuance  of  their  excitement.  In  quiet, 
untidy  patients  the  habit  may  be  in  part  overcome  by  the  regular  use 
of  enemas.  In  patients  partially  paralyzed  uncleanliness  is  due  to 
insufficient  innervation  of  the  sphincters,  and  this  weakness  some- 
times may  be  overcome  by  the  administration  of  nux  voniica,  which 
increases  the  reflex  tone.  In  melancholies  and  hypocliondriacs  incon- 
tinence is  sometimes  due  to  hyperesthesia  of  the  mucous  membrane. 


^Schule  refers  the  symptom  of  uncleanliness  to  (1)  mental  dullness  and 
motor  insufficiency  (dementia  and  states  of  mental  exhaustion),  (2)  impulse 
to  motor  activity  (mania),  (3)  delusions  (paranoiac,  melancholic),  and  gives 
therapeutic  advice. 


GENERAL  TIIKRAPY.  2fi9 

The  slightest  irritation  is  sufficient  to  induce  relax.iiion.  Dngoiu't 
reconimcnds  the  use  of  heliadonna  in  such  cases. 

Care  that  there  he  sufficient  warmth  in  the  room  is  a  part  of  the 
hospital  arrangement.  Many  patients  undress  themselves  contin- 
ually, and  often  tear  their  clothing;  thus  expense  is  increased,  and 
the  patient  is  in  danger  of  taking  cold.  Clothes  made  in  one  piece 
of  strong  material,  with  fastenings  which  the  patient  cannot  undo; 
and  leathern  gloves  with  locks  similarly  arranged,  are  often  useful 
to  oppose  such  tendencies.  Where  this  cannot  he  done,  the  patient 
is  kept  in  a  warm  room;  and,  if  he  will  not  wear  any  clothing,  he 
may  he  given  seagrass  or  hair  with  which  to  cover  himself.  Some- 
times it  is  only  possible  to  keep  the  patient  in  bed  by  means  of 
mechanical  restraint  (camisole).  There  has  been  much  opposition 
to  this  treatment,  and  with  reason,  for  formerly  restraint  was  much 
abused. 

In  certain  cases  rest  in  bed  is  urgently  demanded,  and,  if  it 
cannot  be  carried  out  otherwise,  restraint  seems  indispensable — as 
in  excited,  decrepit  patients  who  otherwise  would  die  of  exhaustion; 
in  surgical  injuries,  and  disease  of  the  eyes,  in  order  to  save  the  parts 
from  irritation.  Of  course,  the  application  of  mechanical  restraint 
should  be  prescribed  by  a  physician. 

Most  insane  patients  require  careful  attention  to  their  excre- 
tions, since  disturbance  of  consciousness,  delusions,  and  disturbances 
of  innervation  interfere  with  the  regularity  of  these  functions.  In 
obedience  to  the  general  indication  to  avoid  any  enfeebling  treat- 
ment, in  constipation  drastics  should  be  avoided,  and  the  object  to 
be  attained  should  be  sought  by  simple  enemas  or  by  using  Hegar^s 
massive  enemas,  glycerin  enemas,  or  glycerin  suppositories,  or  by  the 
administration  of  natural  or  artificial  mineral  waters  and  salines. 
If  these  means  be  ineffectual,  senna,  rhubarb,  rhamnus,  frangnla, 
castor-oil,  and  cascara  may  bo  tried.  In  patients  who  suffer  with 
dangerous  constipation  and  who  object  to  taking  medicines,  calomel 
(0.5  gram)  in  a  single  dose  is  recommended,  since  it  is  easily  ad- 
ministered in  milk. 

In  many  psychoses  accompanied  by  stupor  respiration  is  imper- 
fect. In  such  cases  the  faradic  current  may  be  useful  in  overcoming 
this  dangerous  condition. 

6.  Important  Symptoms. 

Refusal  of  Food. — The  positive  refusal  of  food  is  an  unfortu- 
nate complication.  In  order  successfully  to  overcome  it,  it  is  abso- 
lutely necessary  to  discover  its  cause.     It  may  have  its  origin  in 


270         GENERAL  PATHOLOGY  AND  THERArY  OF  INSANITY. 

somatic  disturbances  (gastric  catarrh,  angina,  and  coprostasis)  or  in 
mental  canses  (delusions,  hallucinations,  etc.).  Individualized  treat- 
ment is  always  necessary. 

When  refusal  of  food  occurs,  the  first  thing  to  be  done  is  to  put 
the  patient  in  bed  in  order  to  prevent  the  dissipation  of  body-heat 
and  lessen  musx^ular  movement.  The  mouth  should  be  kept  clean  by 
washing  with  salicylic  acid. 

Decision  of  the  question  as  to  when  active  interference  is  neces- 
sary will  depend  upon  the  strength  of  the  patient.  When  the  patient 
is  in  bed  and  his  general  nutrition  is  good,  and  the  mouth  well  cared 
for,  and  if  water  is  taken,  forced  feeding  may  be  dispensed  with  for 
about  a  week. 

If  nutrient  enemas  and  the  injection  of  nutrient  fluids  into  the 
mouth,  and  the  use  of  invalid  cups  with  tubes,  are  not  sufficient, 
then  it  is  necessary  to  resort  to  forced  feeding. 

Thanks  to  tubes  made  of  soft  rubber,  this  may  be  carried  o\it  through 
the  nose  with  the  aid  of  a  rubber  syringe  -without  difficulty.  Before  nourish- 
ment is  forced  through  the  tube,  it  must  be  ascertained  whether  the  tube  has 
really  entered  the  stomach  and  is  not  in  the  pharynx,  or  bent  up  in  the  mouth, 
or  possibly  in  the  trachea.  Coughing,  attacks  of  suffocation,  distress,  cyanosis, 
inspiratory  and  expiratory  sounds,  indicate  the  position  of  the  tube.  Expira- 
tory sounds  alone  may  be  caused  by  the  passage  of  air  from  the  stomach. 

As  the  surest  means  of  determining  whether  there  be  danger,  Kräpelin 
recommends  auscultation  of  the  stomach  while  air  is  blown  into  it  through  the 
tube.  The  fluid  nourishment  administered  through  the  tube  must  not  contain 
solid  matter  to  obstruct  it  (milk,  eggs,  bouillon,  codliver-oil,  Avine,  Qtc).  The 
fluid,  since  it  reaches  the  stomach  directly  and  is  not  warmed  by  the  vessels 
and  tlie  mouth,  should  be  administered  lukewarm. 

The  mouth  and  nose  rnust  be  free  of  fluids  during  the  feeding,  "\\hen  a 
few  drops  of  the  fluid  have  been  injected,  and  the  passage  to  the  stomach  is 
shown  to  be  free,  then  the  feeding  is  to  be  finished  as  quickly  as  possible.  In 
general,  two  feedings  a  day  are  sufficient.  In  a  patient  that  has  refused  food 
for  a  long  time  and  whose  stomach  has  bqcome  irritable,  the  first  time  but  a 
small  amoimt  of  unirritating  food  should  be  given  (milk  and  eggs)  ;  otherwise 
vomiting  may  occur.  If  there  be  a  tendency  to  vomit,  a  few  drops  of  chloro- 
form may  first  be  given.  If  the  patient  regurgitate  the  food,  and  if  the  fluid 
accumulate  in  the  pharjaix,  the  tube  must  he  removed  as  quickly  as  possible. 

Forced  feeding  is  sometimes  the  only  means  to  save  the  life  of  a  patient. 
It  must  not  be  used  too  early,  nor  should  its  employment  be  put  ofl"  too  long. 
Its  dangers  are  the  entrance  of  food  or  mucus  into  the  ai-r-passages  and  the 
possible  occurrence  of  pneumonia  or  gangrene  of  the  lung. 

Precoedial  Distress.  —  This  symptom  requires  unremitting 
watching,  for  at  any  moment  the  patient  may  injure  himpelf  or  com- 
mit violence  toward  others.  In  mild  cases  lukewarm  baths,  sinapisms 
over  the  stomach,  bitter  almond-water,  or  extract  of  belladonna  may  ■ 


GENERAL  THERAPY.  271 

be  sufficient.  Anemic  patients  in  a  reduced  physical  state  should  be 
kept  in  bed. 

In  severe  cases  opiates  are  decidedly  useful.  Where  the  pulse  is 
small,  wanting  in  force,  and  infrequent,  opiates  in  connection  with 
acetic  ether  should  he  prescribed.  Where  the  pulse  is  frequent  and 
the  action  of  the  heart  stormy,  they  should  be  combined  with  tincture 
of  digitalis.  Opium  seems  most  effectual  when  administered  subcu- 
taneously  (precordial  distress),  especially  when  the  distress  is  accom- 
panied by  neuralgias  or  paralgias  (injection  at  the  painful  point). 

Chloral  hydrate  also  may  overcome  attacks  of  precordial  distress 
in  onanists,  and  especially  in  neurasthenics. 

Hallucinations.- — Michea  and  others  of  the  older  authorities 
recommend  the  tincture  of  stramonium  to  overcome  hallucinations. 
Modern  opinion,  owing  to  knowledge  of  the  varying  significance  and 
'  origin  of  hallucinations,  places  no  reliance  upon  a  specific.  The 
psychic  element  of  hallucinations  is  not  amenable  to  any  direct  treat- 
ment; they  must  be  treated  like  other  mental  phenomena. 

To  overcome  auditory  hallucinations  dependent  upon  sensory  hyperes- 
thesia, the  quieting  anelectrotonic  effect  of  the  constant  current  may  be  tried. 
Similar  conditions  (unvarjang  hallucinations  with  erethism)  I  have  treated 
with  favorable  results  by  the  methodic  administration  of  morphine. 

Light  and  noise  are  in  such  cases  not  without  influence.  Certain  patients 
have  more  visions  in  the  dark  (delirium  tremens). 

Patients  subject  to  auditory  hallucinations  often  hear  more  voices  when 
they  are  isolated.  These  facts  should  be  considered,  but  they  do  not  justify  a 
general  rule.  Auditory  or  visional  hallucinations  arouse  the  suspicion  of  a 
peripheral  cause  and  call  for  ophthalmoscopic  or  auricular  examination,  which 
may  give  indications  for  treatment. 

II.  Psychic  Teeatment. 

Psychic  treatment  of  patients  is  no  less  important  than  somatic  ;^ 
indeed,  its  range  of  application  is  still  more  extensive.  Here  it  is 
not  a  drug  that  the  physician  prescribes,  but  a  remedy  that  he  creates 
in  himself  and  dispenses,  either  as  a  part  of  his  personal  influence 
or  as  dependent  upon  the  arrangement  of  his  hospital  and  its  regu- 
lations. 

Clinical  psychiatry  has  for  one  of  its  objects  the  development  of  this  im- 
portant aspect  of  medical  knowledge  and  homiletics.  It  is  necessarily  a  part 
of  the  education  of  the  physician,  and  it  bears  its  best  fruit  even  at  the  bed- 
side of  those  only  physically  ill,  for  correct  diagnosis  and  prescription  do  not 
constitute  the  full  duty  of  the  physician,  but  much  depends  also  upon  his 
manner  with  the  patient  and  the  personal  impression  he  makes.  Charlatans 
are  often  better  psychic  physicians  than  the  doctors  themselves.     The  actual 


272  GFA'RRAL  PATHOLOGY  ANH  TllERArY  OK  JNSAXITY. 

rcbiiKs  attained  by  niiiaculuus  pictures,  ijilgiimages,  holy  images,  lioly  waters, 
conjurations,  and  the  like,  at  least  indicate  the  power  of  faith  and  tiust  in 
mental  healing.  The  diagnostic  acumen  and  therapeutic  knowledge  of  two 
physicians  is  often  equal;  and  yet  their  results  are  dilTcrent,  because  the  art 
(if  menial  Ircalnnnl  makes  a  dilTerence.  Many  physicians  possess  the  power 
as  a  natural  talent,  and  use  it  instinctively;  and  they  luive  always  been  the 
greatest  wlio,  along  with  science,  have  consciously  applied  the  principles  of 
mental  treatment  learned  from  experience. 

It  seems  almost  impossible,  where  one  individual  comes  in  men- 
tal contact  with  anoUier  and  an  interchange  of  psychic  influence 
takes  place,  to  give  rules  for  action.  They  can  be  applied  only  from 
a  general  standpoint  to  certain  phases  of  a  disease,  and  become  in 
this  sense  an  object  of  study.  The  concrete  case  docs  not  lend  itself 
to  generalization,  just  as  psychic  materia  medica  is  inexhaustible;  in 
one  case  perhaps  a  glance,  a  M'ord;  in  another,  the  granting  of  a  wish 
or  the  offer  of  a  pinch  of  snuff  exercises  its  healing  influence.  In 
this  individualization  lies  the  interest,  as  well  as  the  difficnlty,  of 
psychic  treatment,  which  may  be  learned,  but  hardly  methodically 
taught. 

In  the  psychic  treatment  of  the  insane  two  phases  of  the  disease 
must  be  distinguished  with  the  greatest  clearness:  The  period  of 
origin  and  the  acme,  and  the  change,  either  to  recovery  or  dementia. 

During  the  development  and  at  the  height  of  the  disease  the 
task  of  mental  treatment  is  properly  negative — the  removal  of  in- 
jurious mental  influences:  efforts  to  distract,  amuse,  teach;  religious 
influences;  threats  and  exorcism.  All  such  efforts  can  do  only  harm, 
since  they  excite  and  embitter.  The  fundamental  necessity  in  all 
mental  therapy  at  this  stage  of  the  disease  is  to  place  the  patient  in 
the  greatest  possible  mental  quietude. 

The  melancholic  requires  this,  because  painful  impressions  are  excited  by 
all  psychic  activity,  even  those  that  are  in  themselves  normally  pleasant;  the 
maniac,  because  his  cerebral  excitement  is  otherwise  intensified;  and  exhausted 
patients  require  it  because  every  mental  impression  exhausts  them  still  further. 

It  is  most  unwise  to  attempt  to  overcome  delusions  by  argument.  De- 
lusions are  symptoms  due  to  cerebral  disease,  and  depend  upon  and  disappear 
with  that  disease;  therefore  discussion  and  argmnent  are  without  avail.  It 
is  better  to  remain  passive  before  them,  to  simply  ignore  them,  to  lead  the 
conversation  to  another  subject,  and  avoid  everything  that  might  recall  them 
to  the  patient.  The  patient  should  be  isolated  as  much  as  possible  with  his 
own  delusions.  It  would  be  an  error  to  fall  in  with  the  delusion  and  thus 
strengthen  it. 

In  many  cases,  however,  treatment  that  is  simply  passive  and 
limited  to  the  removal  of  injurious  mental  influences  is  insufficient. 
The  patient  requires  actual  isolation.    Often  sufficient  isolation  from 


GENERAL  TIT1-:RAI'Y.  273 

external  injurious  irritation  is  obtained  in  an  asylum  wiih  its  physi- 
cal and  mental  dietetic  regulations.  Such  a  change  at  one  stroke 
removes  the  patient  from  the  ridicule  of  others;  from  the  ignorance 
of  well-intentioned  friends  and  relatives;  from  the  excitement  of 
social,  family,  and  public  life;  and  from  the  dangerous  influences  of; 
improper  and  ill-timed  religious  impressions;  he  is  placed  in  new 
and  favorable  surroundings,  and  his  disease  is  subject  only  to  the 
effect  of  isolation.  But  the  asylum  also  has  at  hand  an  impoj'tant 
and  effectual  remedy  in  complete  isolation  of  the  patient,  attained  by 
placing  him  alone  in  a  room. 

Frcqiie7itly  the  isolation  room  is  employer!  for  adminislratiAO  reasons, 
owing  to  the  dangerousness  of  the  patient  either  to  himself  or  others,  or 
owing  to  uncleanliness,  noise,  etc.;  but  it  should  not  be  forgotten  that  it  is 
one  of  the  most  valuable  means  of  quieting  and  cure  the  physician  possesses. 
However,  it  can  be  used  only  by  the  experienced.  Thus,  if  it  be  employed  at 
an  improper  time  or  if  its  use  be  too  long  continued,  it  may  do  great  harm  to 
the  patient. 

Its  indications  are  the  more  pronounced  states  of  mental  or  sensory 
hyperesthesia,  or  great  irritability  of  a  patient  who  cannot  endure  contact 
with  others,  or  who,  in  such  contact,  is  constantly  excited  by  it,  as  in  cases  of 
active  melancholia  or  mania  at  their  height. 

The  isolation  in  its  broadest  sense,  with  reference  to  the  strictness  Avith 
which  it  is  employed,  should  correspond  alwaj^s  with  the  state  of  excitement 
and  excitability  of  the  patient. 

At  the  height  of  the  disease,  when  hyperesthesia  of  the  sense-organs  is 
greatly  intensified,  the  room  must  be  darkened,  and  at  night  it  should  only  be 
dimly  lighted.  By  appropriate  arrangements,  noises  from  outside  should  be 
prevented.  A  noisy  ward  in  an  insane  asylum,  like  those  frequently  noted,  can 
have  no  other  purpose  than  the  temporary  care  of  patients;  as  a  means  of 
cure,  it  is  worthless. 

The  intercoiu'se  of  the  nurses  with  the  patient  must  be  redticed  to  a 
minimimi.  If  the  excitement  of  the  patient  diminish,  then  appropriate  dimi- 
nution of  the  isolation  is  indicated:  more  daylight  is  allowed,  and  more  fre- 
quent intercourse  with  the  nurses;  occupation  Avith  light  reading  and  work; 
change  to  an  ordinary  room,  which  at  first  should  belong  to  the  patient; 
temporary  cessation  of  isolation  in  walks  with  an  attendant;  intercourse  with 
other  patients  and  other  persons  of  the  institution. 

Finally,  the  isolation  of  the  institution  itself  is  interrupted  by  resuming 
relations  and  correspondence  with  others;  visits  from  friends  and  later  from 
relatives;    visits  to  surrounding  places  of  interest  and  pleasure. 

In  the  period  when  the  disease  changes  for  better  or  worse 
psychic  therapy  has  an  active  part  to  play.  The  art  of  the  alienist  is 
here  displayed  in  his  understanding  of  the  individuality  of  the  pa- 
tient to  lead  up  to  the  restoration  of  the  former  mental  personality, 
or  at  least  to  save  all  that  is  possible  out  of  the  mental  wreck. 


2T4  GENERAL  PATHOLOGY  A\D  TTTFRArY  OF  TXSAXTTY. 

Innumerable  patients  recover  (luiekly  and  spontaneously  when  improve- 
ment is  onee  established,  and  the  well-regulated  liospital  for  the  insane,  with 
its  library,  its  music,  its  amusements,  parks,  and  means  of  employment,  has 
only  to  place  these  means  at  tlie  disposal  (if  patients  with  a  reasonable  regu- 
lation of  their  emjdoyment. 

With  many  patients,  however,  at  the  tuniing-point  of  their  disease,  posi- 
tive  interference -is  necessary  in  order  to  free  tliem  from  the  habit  into  which 
they  have  been  forced  oy  their  mental  disease. 

In  snch  cases  any  delusions  tliat  still  exist  must  be  shaken,  nut  by  logic 
and  argument,  but  by  the  friendly  influence  of  ridicule  and  encouragement. 
Surprise  by  letters  or  visits  from  relatives  supposed  to  be  dead  often  aid  in 
removing  the  last  doubt.  One  of  the  best  means  to  help  the  patient  in  a  re- 
turn to  himself,  and  to  free  him  from  the  remains  of  his  disease,  is  work  in 
harmony  with  his  previous  occupation  and  individual  circumstances,  especially 
garden  and  farm  work,  which  at  the  same  time  strengthens  the  body.  Some- 
times gentle  compulsion  is  necessary,  and  even  careful  education  by  praise  or 
slight  punishments  may  be  necessary,  in  order  to  re-create,  as  it  were,  the 
mental  personality.  Too,  in  cases  where  the  termination  of  the  disease  is 
unfavorable,  and  mental  weakness  supervenes,  mental  therapy  has  a  wide 
field.»  In  such  cases  we  must  save  what  there  is  to  save,  and  keep  the  patient 
from  sinking  into  deep  dementia.  The  principal  means  for  tliis  piu-pose  are 
occupation  for  the  patient  and  keeping  him  well  ordered  and  clean. 

Innumerable  unfortunates,  who,  if  left  to  themselves,  would  degenerate 
into  filth  and  complete  dementia,  the  regulations  of  a  hospital  for  the  insane 
keep  at  a  useful  mental  level  and  make  the  employment  of  the  mental  powers 
that  remain  useful.  Sometimes  delusions  of  grandeiu*  keep  such  patients  from 
working,  or  give  to  their  conduct  a  perverse  direction.  In  such  incurable 
cases,  with  the  disappearance  of  the  emotional  accompaniment,  repression  of 
the  delusions  may  be  indicated,  to  prevent  action  in  obedience  to  them. 

Leuret  in  this  sense  created  a  so-called  moral  treatment,  and  thought 
that  he  cured  such  patients  by  intimidation.  Of  course,  there  was  no  such 
thing  as  cure,  but  simply  mental  training,  which,  however,  had  a  certain  value 
for  the  patient  and  those  associated  with  him.  Convenient  measures  for  dis- 
ciplining such  patients  are  found  in  the  faradic  brush  and  rain-douches. 

Treatment  dy  Hypnotic  Suggestion. 

Considering  the  want  of  effect  of  simple  suggestion  in  mental  dis- 
ease, and  the  great  effect  of  hj-pnotic  treatment  in  the  neuroses,  the 
employment  of  this  powerful  means  of  mental  treatment  in  cases  of 
insanity  immediately  suggests  itself. 

In  fact,  it  woidd  be  a  great  gain  to  influence  the  feelings,  thoughts,  and 
impulses  of  such  patients,  and  by  suggestion  to  overcome  dangerous  or 
troublesome  sjTuptoms,  such  as  hallucinations  and  delusions.  But  for  those 
experienced  in  psychiatry  hypnotism  can  only  be  employed  with  doubt  as  to 
the  result;  because  (1)  insane  patients  are  only  exceptionally  capable  of  that 
state  of  att-ention,  passivity,  feeling,  and  will,  necessary  to  the  successful  in- 
duction of  hypnosis;  (2)  because  many  mental  diseases  depend  upon  organic 
changes  in  the  brain,  and  suggestive  treatment  can  efi"ect  only  functional  dis- 


GENERAL  THERAPY.  275 

turbanoes;  {^)  hpcauso  cei'tain  synipioiiis,  wiK-h  as  many  rlfliisions  und 
hallucinatioiKS,  even  though  they  are  not  deinonwtrably  the  result  of  organic 
'changes,  are  yet  so  complicated  and  so  intimately  interwoven  with  the  mental 
mechanism  that  it  hardly  seems  possible  to  influence  them  by  suggestion,  and 
it  is  difficult  to  formulate  suggestions  to  overcome  them. 

Thus  theoretically  it  is  presumable  that  successful  treatment  by  hypnotic 
suggestion  can  only  be  expected  in  functional  psychoses,  and,  too,  in  patients 
that  are  aware  that  they  are  sick,  and  who  lend  themselves  to  hypnosis. 

In  general,  conditions  appropriate  for  such  treatment  may  be  enumerated 
as  follows:  Simple  disturbances  of  mental  feeling;  formal  disturbances  of 
thought,  especially  imperative  conceptions  and  delusions,  when  they  are 
merely  autosuggestions  based  upon  false  ideas,  and  not  primordial  delusions, 
or  explanatory  delusions  of  melancholia;  and  finally  acquired  abnormal  in- 
stinctive impulses.  Following  ordinary  psj'chiatric  terminology,  it  might  be 
possible  to  apply  such  treatment  in  melancholia  without  delusion;  in  the 
majority  of  neuropsychoses,  especially  hysteria,  hypochondria,  neui-asthenia. 
and  the  psychoses  in  the  form  of  imperative  ideas;  in  those  dependent  upon 
alcohol,  cocaine,  chloral,  or  nicotine;  and  in  mental  impotence  and  contrary 
sexual  instinct. 

In  general,  the  result  corresponds  with  the  theoretic  limitations  and  the 
circumstances.  According  to  the  experience  of  myself  and  others,  the  treat- 
ment seems  effectual,  not  only  in  abnormal  moods,  emotions,  feelings,  impulses, 
and  even  abnormal  ideas  and  hallucinations,  but  also  in  physical  disturbances, 
such  as  sleeplessness,  loss  of  appetite,  constipation,  neuralgia,  etc. 

Many  observers  in  all  countries  report  success  in  melancholia 
without  delusion;  in  delusional  insanity,  especially  alcoholic  and 
hysteric  and  in  the  hysteric  psychoses ;  in  chronic  intoxication,  espe- 
cially alcoholism  and  morphinism.  The  results  of  hypnotic  treat- 
ment in  dipsomania  and  contrary  sexual  instinct  (von  Schrenck- 
jSTotzing)  are  worthy  of  remark.  Folie  du  doute  is  often  favorably 
influenced.  Symptomatic  manifestations  of  abnormal  instinctive  im- 
pulses, especially  those  that  are  sexual  or  alcoholic,  and  the  desire 
for  morphine  and  cocaine,  are  influenced  by  suggestive  treatment. 


CHAPTER  VI. 

Treatment  During  the  Period  of  Convalescence. 

DuKiNG  the  period  of  convalescence  the  patient  also  has  great 
need  of  the  physician^s  care.  The  physical  and  mental  process  of 
restoration  must  be  watched,  and  the  slighter  indications  of  the  dis- 
ease passed  through  must  be  taken  into  account.  The  cure  of  vege- 
tative disturbances,  such  as  anemia  and  uterine  disease  that  exercised 
an  injurious  influence,  must  be  completed.  Often,  for  a  long  time, 
sleeplessness  continues,  and  requires  care  and  proper  medical  at- 
tention. 


o7f,  GKNKRAT.  I'AlllOl.OGY  AND  TIIKIIAPY  OF  lIsSAXl  TV. 

It  is  only  necessaiy  to  mention  that  the  enfeeblement  and 
physical  exhaustion,  like  that  which  follows  severe  diseases,  are  nol 
to  be  treated  with  stimulating  remedies,  but  by  dietetic  means.  The 
convalescent  patient  is  still  ^eak  mentally  and  very  sensitive,  and 
longs  to  be  again  with  his  family  and  take  up  his  occupation.  Under 
such  circumstances  it  is  better  to  temporize.  Too  early  visits  from 
relatives  should  be  prevented,  since  they  lead  usually  to  too  early 
discharge  of  the  patient  from  treatment,  and  thus  favor  relapses. 
Too  early  discharges  are  always  dangerous,  especially  when  the  con- 
valescent returns  to  his  former  misery,  and,  as  is  often  the  case,  to 
ridicule,  mistrust,  and  unsympathetic  treatment. 

Every  convalescent  should  be  kept  for  a  time  in  quarantine,  as 
it  were,  before  he  is  allowed  to  leave  the  institution,  in  order  grad- 
ually to  test  his  powers.  In  some  cases,  when  the  mental  powers  are 
defective  and  the  individuals  are  irritable  and  troubled  with  home- 
sickness, it  is  dangerous  to  keep  them  a^\'ay  from  home  too  long. 
Under  such  circumstances  it  is  necessary  to  choose  the  lesser  of  two 
evils  and  discharge  the  patient  in  order  to  prevent  a  relapse  with  the 
patient  still  in  the  institution. 

Where  circumstances  permit  it,  the  convalescent,  before  return- 
ing to  his  former  surroundings,  should  be  led  up  to  it  by  a  sojourn  in 
the  family  of  friends  or  in  the  country,  or  by  travel.  Along  with 
this  sometimes  other  medical  prescriptions  may  be  combined,  such  as 
sea-bathing,  water-cures,  or  a  sojourn  in  an  appropriate  climate,  etc. 


BOOK  III 

Special  Pathology  and  Therapy  of  Insanity. 


INTRODUCTION, 
Classification  of  the  Psychoses — Forms  of  Insanity, 

The  fundamental  premise  in  the  establishment  of  the  special 
pathology  of  insanity  is  the  classification  and  grouping  of  disease- 
pictures;,  individually  so  different  and  confusing  in  their  varieties, 
according  to  a  uniform  plan. 

The  need  of  a  satisfactory  classification  of  mental  diseases  was 
early  felt,  and  led  to  innumerable  attempts  at  classification,  of  which, 
hoAvever,  none  has  ever  been  generally  and  unconditionally  accepted. 
jSTotwithstanding  the  difficulty  of  such  an  effort,  in  the  interest  of 
science,  as  well  as  to  promote  an  understanding  between  author  and 
student,  it  must  be  attempted. 

The  first  question  is :  according  to  what  principles  in  the  present 
state  of  the  development  of  psychiatry  should  such  an  effort  be  made  ? 

In  pathology  there  are  three  principles  of  classification:  ana- 
tomic, in  accordance  with  the  anatomic  changes  at  the  foundation 
of  the  diseases;  etiologic,  according  to  the  special  causes;  clinical 
and  functional,  according  to  the  manner  in  which  functions  are 
changed  by  the  disease-process. 

There  can  be  no  thought  of  an  anatomic  classification  of  the 
psychoses.  We  know  too  little  of  the  anatomic  processes  of  which 
the  phenomena  of  insanity  are  the  clinical  expression,  to  say  nothing 
of  anatomic  differences.  However,  from  the  great  nimiber  of  psy- 
choses, which  to-day  are  regarded  as  purely  functional  brain  diseases, 
a  group  may  be  separated  in  which  pathologico-anatomic  changes  are 
never  wanting.  When  in  certain  symptom-complexes  this  anatomic 
substratum  is  identical,  the  clinical  name  of  the  disease  may  be  re- 
placed by  an  anatomic  term,  or  at  least  the  latter  may  be  added  to  the 
former. 

(277) 


;?:S  SPK(i.\l.  I'ATIKH.nnV  AND  THETtAPY  OF  INSANITY. 

These  cerebral  diseases  with  preclominating  mental  symptoms  in 
the  narrower  sense — or  organic  psychoses  in  contrast  with  fnnctional 
psychoses — constitute  tlie  transition  from  special  psychiatry  to  spe- 
cial cerebral  ])athology,  from  which  they  are  separated  only  practi- 
cally by  the  predominance  of  mental  disturbances.  These  latter, 
however,  are  not  independent,  as  in  the  psychoses  in  a  strict  sense, 
but  entirely  dependent  upon  the  intensity  and  extent  of  anatomic 
changes  (Scliiile).  Therefore  they  do  not  follow  the  psychologic  de- 
velopment and  course  of  ordinary  psychoses,  but  present  symptoms 
of  a  concomitant  affection  of  the  psychic  organ  contemporaneous 
with  a  grave  cerebral  disease.  Since,  as  a  i-ule,  the  latter  is  progress- 
ive, there  is  always  an  increasing  and  iiu'urable  disturbance  of  the 
psychic  organ  (dementia)  in  case  the  anatomic  disease-process  has 
not  too  early  invaded  vital  centers  and  proved  fatal. 

Since  siu-li  a  disease-process  passes  beyond  the  cortical  areas  of 
the  brain  and  involves  infracortical  centers  and  nervous  paths,  the 
disease-picture  is  not  limited  to  psychic  and  psychomotor  phenomena, 
but  presents  motor,  sensory,  and  vasomotor  disturbances  of  functions 
that  are  combined  with  psychic  symptoms  and  have  equal  value.  The 
disease-pictures  belonging  in  this  category,  with  evident  cerebral 
changes,  are  the  following:  1.  Acute  delirium.  2.  General  paralysis 
of  the  insane.  3.  Cerebral  hies  in  the  sense  of  diffuse  luetic  disease 
of  the  convexity.    4.  Senile  dementia. 

An  etiologic  classification  promises  more,  with  the  assumption 
that  insanity  arising  out  of  definite  causes  presents  certain  peculiari- 
ties of  symptoms  and  course  which  permit  a  reference  of  the  disease 
to  the  cause  with  certainty.  Unfortunately  this  assumption — a  spe- 
cific canse  with  specific  peculiarities  of  the  disease-picture^^is  not 
sufiiciently  justified  in  general  to  be  elevated  to  a  general  principle. 

With  few  exceptions,  insanity  is  the  effect  of  the  combined 
influence  of  various  canses  the  individual  valuation  of  which  is 
difficult;  the  manner  of  producing  the  effect  is  often  obscure;  the 
clinical  expression  is  equivocal  and,  owing  to  interaction,  devoid  of 
clearness.  In  recognizing  the  efforts  of  Morel,  Skae,  Clouston,  Kahl- 
baum, and  others  in  this  direction,  it  must  be  admitted  that  an  etio- 
logic classification  of  insanity  at  the  present  time  is  impossible,  even 
thongh  in  the  single  case  the  etiologic  moment  must  be  taken  into 
consideration. 

However,  if  the  hope  is  not  fulfilled  that  a  given  cause, — such  as 
injurv  of  the  head,  lues,  nterine  disease, — even  if  it  be  the  only  cause 
acting,  owing  to  the  difference  of  pathogenesis,  localization,  etc., 


CLARSTFICATTON  01^  PSYCHOSES— FORMS  OF  INSANITY.       279 

cannot  produce  a  disease-picture  distinct  in  its  course  and  symptoms, 
still  it  may  be  expected  that  certain  influential  causal  factors,  like 
heredity,  constitutional  condition,  or  poisons,  might  cliaractcrizc  an 
entire  group,  even  of  varied  disease-pictures,  by  common  symptoms 
and  a  common  course. 

With  the  assumption  of  the  correctness  of  this  view,  the  use  of 
the  etiologic  factor,  at  least  in  the  separation  of  the  larger  groups 
of  insanity,  seems  justified  and  useful,  in  that  it  permits  a  reference 
of  the  cases  from  their  pathogenesis,  course,  and  symptoms  to  a  par- 
ticular constitutional  foundation. 

In  fact,  it  makes  a  fundamental  difference  whether  the  psychic 
disturbance  develop  in  a  robust  brain  well  constituted  and  with 
normal  functions  from  birth,  or  whether  it  be  the  expression  of  an 
invalid  brain,  heröditarily  burdened,  or  otherwise  unfavorably  influ- 
enced in  its  development.  This  fact,  which  was  thoroughly  appreci- 
ated by  Morel,  and  which  later  Schule  emphasized,  makes  it  neces- 
sary to  distinguish  most  carefully  the  psychoses  occurring  in  the 
normally  developing  and  normally  developed  brain,  in  accordance 
with  the  presence  or  absence  of  hereditary  factors  having  etiologic 
importance. 

Mental  disturbances  that  affect  individuals  of  robust  brain  may 
be  called  23sychoneuroses.  Those  developed  upon  a  defective  founda- 
tion may  be  called  degenerate  insanities.  It  need  scarcely  be  added 
that  these  two  grand  groups  cannot  be  strictly  differentiated,  for,  as 
in  all  other  departments  of  organic  life,  they  present  transitional 
cases.  Thus,  it  may  be  questionable  whether  an  individual  with  bad 
mental  ancestry,  who  up  to  the  time  of  his  insanity  was  normal,  is 
to  be  placed  in  one  or  the  other  of  these  groups.  Moreover,  a  well- 
constituted  brain  may,  as  result  of  head  inj\iry  or  other  cause  (drunk- 
enness), acquire  a  degenerate  constitution  which  gives  a  degenerate 
character  to  any  accidental  psychosis. 

Too,  it  is  not  merely  the  etiologic  factor  that  justifies  the  dif- 
ferentiation; there  are  also  other  peculiarities  in  the  origin,  course, 
and  grouping  of  symptoms  upon  which  the  differential  diagnosis  rests. 
Even  Morel  recognized  these  clinical  peculiarities  of  degenerate  in- 
sanity, but  he  attributed  them  exclusively  to  heredity.  This  view 
must  be  enlarged,  since  hereditary  degeneration  constitutes  only  one 
important  aspect  of  degenerate  insanity  in  general,  which,  however, 
may  have  its  origin  in  acquired  degeneracy  (in  trauma,  brain  dis- 
eases, anomalies  of  development,  etc.). 

The  etiologic  and  clinical  points  serving  to  distinguish  the 
psychoneuroses  from  states  of  psj^hic  degeneration,  which  I  have 


380 


SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 


employed  in  my  clinic  for  years  for  didactic  purposes,  and  ^vhit•ll, 
of  course,  are  somewhat  dogmatic,  are  the  following: — 


L  PsYCnoNEvnosEs. 

1.  Parasitic,    accidentally    acquired 

diseases  in-  individuals  whose  cerebral 

functions  were  previously  normal  and 

whose  disease  could  not  be  foreseen. 


2.  Disease  based  upon  temporary 
disposition  (grave  physical  disease 
and  the  simultaneous  action  of  pow- 
erful exciting  causes).  Hereditary 
predisposition  not  excluded,  but  only 
latently  present  in  the  brain  of  one 
easily  afl'ected,  but  previously  normal 
in  its  functions. 


3.  Tendency  to  cure  of  the  disease 
and  infrequency  of  relapses. 


4.  Slight  tendency  to  transmission 
to  descendants,  and,  when  it  occurs, 
in  benign  forms   (psychoneuroses). 

5.  Typic  coiu-se  of  the  disease-pic- 
ture. Mania,  as  a  rvle,  arises  from  a 
melancholic  initial  stage;  and  so- 
called  secondary  conditions  are  the 
terminations  of  primary  conditions. 
The  disease-picture,  even  when  it  ap- 
pears, has  an  independent  form — has 
a  certain  dirration  and  independence. 
The  whole  course  of  the  disease  is 
quite  narrowly  limited  in  time,  and 
goes  on  either  to  recovery  or  de- 
mentia. 


II.  Psychic  Degenerations. 

1.  Constitutional, — i.e.,  diseases  hav- 
ing their  basis  in  the  whole  consti- 
tution; diseases  in  individuals  who 
from  their  earliest  childhood  betray 
a  neuropsychopathic  constitution,  the 
functions  of  whose  central  nervous 
systems  were  always  in  a  state  of  lui- 
stable  equilibrium,  and  the  loss  of 
Avhich  was  to  be  feared. 

2.  Slight  exciting  causes,  even 
physiologic  phases  of  life, — puberty, 
menses,  puerperal  state,  climacteric 
disease,  for  the  most  part  conditioned 
by  pathologic  and  usually  hereditary 
predisposition;  or  by  the  continued 
efi'ect  of  injurious  influences  (trauma 
capitis,  acute  brain  diseases,  etc.), 
which,  for  the  most  part,  affect  the 
brain  during  its  development.  In 
these  cases  frequently  the  psychic  dis- 
ease is  the  last  link  in  a  chain  of  neu- 
ropathic conditions,  passing  always 
from  one  to  another  severer  form 
(neurasthenia,  hysteria,  hypochon- 
dria, epilepsy). 

3.  Slight  tendency  to  cure;  for  the 
most  part,  only  temporary  return  to 
the  status  quo  ante;  great  tendency 
to  relapses  and  development  of  more 
severe  forms  of  disease. 

4.  C4reat  tendency  to  transmission, 
with  progressive  increase  in  the  grav- 
ity of  the  form  of  disease  (progressive 
hereditary  degeneration). 

5.  All  forms  of  the  psj'choneuroses 
are  possible  here,  but  they  appear 
principally  in  the  graver  organic 
forms.  The  course  cannot  be  pre- 
dicted. There  is  curious  and  irregular 
variation  of  the  various  forms,  with 
inexplicable  and  abrupt  single  series 
of  sAnnptoms.  The  form  is  of  short 
duration,  and  is  also  not  pure,  but 
rather  a  mixture  of  various  forms. 
Thus,  the  whole  disease  has  a  protean 
character,    and    cannot    be    classified 


CLASSIFICATION  OF  FSYCHOSES— FORMS  OF  INSANITY.       £81 

I.  PsYCHONEUROSES  (Continued).  II.  Psychic    Degenerations    (Con- 

tinued). 
according  to  a  physio-psychologic 
principle  of  classification.  The  gen- 
eral course  is  chronic  and  may  con- 
tinue throughout  the  rest  of  life,  at 
the  same  time  remaining  at  a  certain 
stage  of  development,  and  leading  to 
dementia  only  late  or  not  at  all.  In 
other  cases  of  grave  progressive  de- 
generation, on  the  other  hand,  the 
mental  decline  is  rapid. 

6.  No  tendency  to  periodicity  of  6.  Great  tendency  to  periodicity; 
the  attacks  or  the  gi-ouping  of  the  periodic  insanity  is  a  degenerate  man- 
symptoms,                                                         ifestation. 

7.  Sanity  and  insanity  are  sharply  7.  Often  quite  unnoticed  transition 
defined,  and  in  striking  contrast.  from  pathologic  predisposition  to  ac- 
tual disease.  Curious  mixture  of 
lucidity  and  insanity  at  the  height 
of  the  disease,  even  to  the  extent  of 
recognition  of  the  insane  condition. 

Further  subdivision  of  these  two  principal  groups  of  insanity 
in  the  developed  brain  cannot  be  attempted  from  an  etiologic  stand- 
point, for,  in  the  psychoneuroses,  the  etiologic  factor  does  not  play 
an  important  part  in  determining  the  symptoms  and  course,  and,  in 
the  psychic  degenerations,  the  etiologic  factor,  at  least  as  far  as  our 
present  knowledge  goes,  gives  only  certain  clinical  marks  to  the 
whole  group,  without,  however,  permitting  further  differentiation  in 
accordance  with  the  etiologic  factors  of  the  degeneration  itself.  This 
is  especially  true  of  so-called  hereditary  insanity,  which,  though  it 
usually  appears  in  certain  forms  (moral,  periodic,  arising  out  of  trans- 
formation of  the  constitutional  neuroses  to  insanity  of  imperative 
conceptions),  is  not  made  up  of  these  exclusively. 

In  the  further  classification  of  the  psychoneuroses,  a  clinico- 
functional  principle  is  the  only  one  possible.  The  manner  of  group- 
ing of  symptoms  and  the  course  are  of  the  first  importance  in  the 
classification  of  these  typic  conditions,  which  pass  through  a  certain 
course  and  are  the  expression  of  a  systematic  disease-process  in  the 
psychic  mechanism. 

With  reference  to  the  course,  two  insane  conditions  may  be 
differentiated:  the  primary,  and  the  secondary  arising  out  of  the 
former.  This  differentiation  is  also  of  value  from  a  prognostic  stand- 
point, in  that  possibility  of  cure  in  general  exists  only  in  the  primary 
conditious. 


38'2  SPECIAL  PATHOmcV  AND  THKÜAl'Y  OF  IXSAXITV, 

Among  the  primary  disturbances,  other  distinctions  may  be  made 
in  accordance  with  the  nature  of  the  functional  disturbances : — 

(A)  States  of  interference  with  the  activity  of  the  psychic  func- 
tions, going  even  to  inhibition,  together  with  ])ainful  emotional 
states,  with  even  micromania  as  explanation  of  tlie  inhibition  and  de- 
pression. Implication  of  the  central  sensory  spheres  (hallucinations, 
illusions)  is  subsidiary.  All  degrees  of  disturbances  of  consciousness 
are  possible:  melancholia. 

In  melancholia  may  be  distinguished: — 

1.  A  mild  form,  where  there  is  no  deep  disturbance  of  conscious- 
ness and  the  psyoliomntor  inhibition  is  psychically  induced:  simple 
melancholia. 

2.  A  graver  form,  with  deeper  disturbance  of  consciousness,  and 
where  the  inhibition  is  organic  (tetany,  catalepsy):  melancholia  with 
stupor. 

(B)  States  in  which  the  activity  of  the  psychic  functions  is 
facilitated,  even  to  absolute  lack  of  control,  accompanied  by  pre- 
dominating pleasurable  feeling,  reaching  even  the  extent  of  grand 
delusions  as  a  motive  for  the  anomalies  of  psychic  activity  and  feel- 
ing. Implication  of  the  central  sensory  sphere  is  subsidiary.  All 
degrees  of  disturbance  of  consciousness  are  possible:  mania. 

As  in  melancholia,  there  may  be  differentiated  here : — 

1.  A  mild  form,  where  there  is  no  decided  disturbance  of  con- 
sciousness and  the  psychomotor  acts  are  psychically  induced:  ma- 
niacal exaltation. 

2.  A  graver  form,  where  there  is  deeper  disturbance  of  con- 
sciousness and  the  psychomotor  acts  are  organically  induced  by  irri- 
tative processes  in  the  psychomotor  centers:  impulsive  imperative 
movements,  furious  mania. 

(C)  States  of  temporary  diminution  of  psychic  activity,  going 
even  to  its  actual  absence,  inclusive  of  emotional  states,  which  may 
be  temporarily  absent.  This  necessarily  leads  to  grave  disturbance 
of  consciousness,  which  may  go  so  far  as  stupor :  stupidity. 

(D)  States  of  central  excitement  of  the  senses  with  continuance 
of  external  sense-perception.  This  necessarily  leads  to  disturbance 
of  consciousness  (confusion).  Emotional  ,and  motor  anomalies  are 
not  primary,  but  secondary,  manifestations,  dependent  upon  the  con- 
tent of  the  delusions :   primary  hallucinatory  insanity. 

If  these  primary  states  do  not  go  on  to  recovery,  then  they  end 
in  so-called  secondary  states.  These  are  characterized  by  disap- 
pearance of  the  emotional  state;  destruction  of  the  former  person- 
ality and  the  logical  interdependence  of  feeling,  thought,  and  will, 


CLASSTFTCATTONT  OF  PSY('IT0,9KS-F0r!MS  f)F  IXSAXfTY.        ooo 

and  especially  of  co-ordination  of  the  psychic  acts.  As  important 
signs  of  the  occurrence  of  mental  weakness  may  be  mentioned:  The 
loss  of  ethic  and  esthetic  feeling;  the  weakening  of  intellecttia],  and 
especially  of  logical,  activity  (states  of  mental  weakness).  In  these 
conditions;,  depending  npon  whether  the  mental  mechanism  is  kept  in 
relation  more  or  less  complete  with  groups  of  delusional  ideas  and 
acts  in  accordance  with  them,  or  whether  a  general  deterioration  or 
a  general  weakening  of  the  mental  activities  has  taken  place,  two 
conditions  may  be  distinguished:  secondary  paranoia,  and  dementia. 
Clinically,  dementia  may  be  divided  into  an  agitated  and  an  apathetic 
form,  according  to  whether  there  be  activity  in  the  ruined  psychic 
mechanism  expressed  in  incoherent  ideas  and  impulses,  or  absolute 
quiet  and  absence  of  reaction. 

If  we  turn  now  to  the  differentiation  of  the  psychic  states  of 
degeneration,  and  attempt  a  classification  analogous  to  that  of  the 
psychoneuroses,  it  will  be  found  to  be  impossible.  It  is  only  in  iso- 
lated cases  that  the  periodic  recurrence  of  an  attack  is  a  striking 
manifestation. 

These  states  are  seen  to  be  peculiar,  and  diseases  of  the  person 
in  the  strictest  sense  of  the  word,  in  contrast  with  the  psychoneuroses, 
which  are  systematic  psychic  diseases  with  typic  development  and  an 
empirically  clear  and  regular  course.  As  is  shown  by  the  etiology, 
which  has  its  root,  for  the  most  part,  in  hereditary  conditions,  these 
degenerate  states  must  be  considered  from  an  anthropologic  stand- 
point, and  do  not  permit  a  classification  based  upon  a  psychologic 
principle. 

Since  the  etiologic  standpoint  based  on  anthropologic  grounds 
permits  only  a  separation  of  the  whole  group  from  the  psychoneu- 
roses, it  becomes  necessary  to  make  a  further  classification  of  these 
disease  states,  which  are  always  more  or  less  individual,  according  to 
peculiarities  in  the  grouping  of  symptoms,  the  course,  and  the  man- 
ner of  origin. 

The  following  types  may  be  distinguished : — 

(a)  Constitutional  affective  insanity,  characterized  by  the  uni- 
form character  of  the  disease-picture,  which  is  essentially  emotional 
and  presents  only  formal  disturbances  of  thought. 

(b)  Paranoia,  characterized  by  a  change  of  the  personality,  or 
at  least  of  its  relations  to  the  external  world,  even  to  a  degree  where 
a  new  ego  is  formed  dependent  upon  primary  delusions  without  emo- 
tional foundation,  which  quickly  become  systematized.  This  system 
of  delusions  arises  out  of  the  fact  that  consciousness  does  not  undergo 
profound  disturbance,  and  the  power  of  judgment  and  drawing  con- 


284  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

elusions  is  untouched.  The  emotional  states  and  acts  arise  out  of  the 
delusions,  or  are  due  to  them. 

(c)  Insanity  arising  out  of  constitutional  neuroses:  epilepsy, 
hysteria,  neurasthenia,  hypochondria. 

(d)-  Periodic  insanity,  characterized  by  periodic  recurrence,  in 
which  the  content  and  course  of  the  attacks  are  essentially  similar. 

In  contrast  with  these  mental  disturbances  affecting  the  fully 
developed  brain  are  to  be  placed,  finally,  states  of  mental  defect,  the 
cause  of  which  lies  in  injurious  influences  that  alfect  the  brain  during 
fetal  life  or  during  the  period  of  develoj)ment,  as  a  result  of  which 
the  further  development  of  mental  life  is  disturbed :  arrest  of  psychic 
development. 

This  group  may  be  again  divided  into  idiocy  and  cretinism,  de- 
pending upon  whether  the  local  or  constitutional  cause  alfect  merely 
the  psychic  organ  or  induce  at  the  same  time  deformity  of  the 
skeleton  and  the  vegetative"  organs.  '  These  states  of  original  mental 
wealcness  may  manifest  themselves  in  defective  development  of  either 
the  intellectual  or  ethic  functions,  with  manifold  variations  (original 
states  of  mental  weakness).  The  cases  in  which  the  ethic  feelings 
are  specially  defective  are  usually  called  moral  insaniti/. 

The  following  schema  of  classification  is  derived  from  the  fore- 
going principles : — 

(A)   Mental  Diseases  of  the  Adult  Brain. 
/.  Diseases  irithout  anatomico-patliologic  lesions:    functional  psj/- 
choses. 

(A)  Psyclioneuroses:   i.e.,  disease-si ui es  of  the  norinal  and  rohust 

hrain. 

1.  Melancholia  (inhibitory  neurosis  of  the  psychic  organ). 

(a)  ^Melancholia — simple. 

(b)  Melancholia — with  stupor. 

2.  Mania  (neurosis  with  lack  of  inhibition). 
(a)  Maniacal  exaltation. 

(hj  Furious  mania. 

3.  Stupidity,  or  acute  curable  dementia  (neurosis  of  exhaustion). 

4.  Primary  hallucinatory  insanity  (hallucinatory  delirium,  hallucinatory 

psychoneurosis). 

Appendix:  Terminal  states  of  these  conditions  in  incurable  secondary 
delusional  insanity  and  secondarj^  dementia,  with  clinical 
varieties  in  the  agitated  or  apathetic  form. 

(B)  Psychic  degeneration:   i.e.,  disease-states  affecting  tlie  ahnor- 

nial,  predisposed,  or  wecd'ened  train. 
1.  Constitutional  emotional  insanity  (fuUe  rulsoiinantej. 


CLASSTFICA'nON  OF  PSYCHOSES— FORMS  OF  INSANIIT.        285 

2.  Paranoia. 

(a)  Original  form. 

(b)  Acquired  (late  form). 

Persecutory    jianiiioia     (primary    and    predominating    delusions    of 

injury  to  the  personality). 
(a)  Typic  form. 
(h)  Querulous  paranoia. 
(c)  Expansive  paranoia  (primary  and  predominating  delusions  of 

aggrandizement  of  the  personality). 

1.  Paranoia  with  inventive  or  reformatory  ideas. 

2.  Eeligious  paranoia. 

3.  Erotic  paranoia. 

3.  Periodic  insanity. 

4.  Insanity  arising  out  of  tlie  constitutional  neuroses. 
(a)  Neurasthenic  insanity. 

(1))  Epileptic  insanity. 

(c)  Hysteric  insanity. 

(d)  Hypochondriac  insanity. 

II.  Diseases  ivliicli  present  constant  anatomico-patJwIogic  lesion'^: 
brain  diseases  with  predominating  mental  symptoms; 
organic  psychoses. 

1.  Acute  delirium  (transudative  hyperemia  with  transition  to  acute  diffuse 

periencephalitis) . 

2.  Chronic  paralysis,  or  dementia  paralytica   (chronic  diffuse  periencepha- 

lomeningitis ) . 

3.  Cerebral  lues. 

4.  Senile  dementia  (primary  cerebral  atrophy). 

Appendix:    Intoxications  (transitional  groups  between  I  and  II). 

1.  Chronic  alcoholism. 

2.  Morphinism. 

(B)  Arrest  of  Psychic  Development. 

Idiocy  (possibly  with  physical  degeneration,  cretinism). 

(aj  Predominating  states  of  intellectual  defect  (original  mental  weak- 
ness and  dementia). 

(bj  Predominating  states  of  ethic  defect  (original  moral  mental  weak- 
ness and  dementia). 


PART   FIRST. 
Psyclioneuroses — Primary  Curable  States. 


CHAPTER  I. 

Melancholia. 

The  fuiulaiiu'nlal  phcnoineiion  in  inelancholia  consists  of  tlie 
painful  emotional  depression,  wliirli  has  no  external,  or  an  insnlfi- 
cieiit  external,  cause,  and  general  inhibition  of  the  mental  activities, 
which  may  be  entirely  arrested. 

Conceniing  the  inner  basis  and  lehilinn  of  these  two  fundamental  ancmi- 
alies  of  the  psyeliie  mechanism  in  mehmcholics  we  have  only  hypotheses. 

A\'lnle  some  regard  the  painful  depression  as  the  expression  of  a  disturb- 
ance of  nutrition  in  the  psychic  organ  (psychic  neuralgia)  from  Avhich,  as  a 
result,  arises  the  inhibition  of  the  mental  activities,  a  more  recent  theory 
regards  the  inhibition  as  primary,  and  the  psychic  pain  as  a  secondary  mani- 
festation due  to  consciousness  of  the  mental  inhibition.  Both  these  theories 
are  at  best  one-sided.  The  hypothesis  tltat  makes  psychic  pain  secondary  does 
not  accord  with  experience.  It  could  only  be  so  regarded  if  the  intensity  of 
the  psychic  pain  stood  in  proportional  relation  to  the  degree  of  inhibition, 
which,  however,  is  not  the  case,  and  if  the  inhibition  preceded  the  psychic  pain 
in  time;  but  even  this  hypothesis  finds  no  support.  The  first  manifestation 
is  psj-chic  pain;  then  inhibition  follows,  which,  of  course,  becomes  a  new 
source  of  psychic  pain.  The  facts  force  us  to  conclude  that  psychic  pain  and 
inhibition  are  co-ordinated  phenomena,  between  which,  of  course,  a  mutual 
reaction  is  not  excluded.  At  the  same  time  a  confmon  fundamental  cause  may 
be  thought  of:  a  disturbance  of  cerebral  nutrition  (anemia?),  which  leads  to 
lessened  production  of  vital  force. 

Melancholia,  from  a  comprehensive,  nnprejudiced  point  of  view, 
may  be  defined  as  an  abnormal  condition  of  the  psychic  organ  de- 
pendent upon  a  disturbance  of  nutrition,  characterized,  on  the  one 
hand,  by  a  psychic  painful  emotional  state  and  manner  of  reaction 
of  the  whole  consciousness  (psychic  neuralgia),  and,  on  tlie  oilier 
hand,  by  inhibition  of  the  psychic  activities,  feelings,  intellect,  and 
will,  M'hich  may  go  to  the  extent  of  arrest. 

Symptomatology. 

Psychic  Sy'MPTOMS. — The  content  of  the  melancholic  conscious- 
ness is  psychic  pain,  distress,  and  depression,  as  the  expression  of  a 


PSYC'HONEUROSES— PRIMARY  CURABLE  STATES.  2S7 

nutritive  disturbance  of  the  psychic  organ.  This  painCiil  depression. 
in  its  content  docs  not  difi'er  from  the  painful  depression  due  to 
efficient  causes.  The  solidarity  of  the  psychic  activities  causes  the 
depression  to  he  total;  the  psychic  organ  is  incapahlc  of  calling  up 
any  other  than  painful  psychic  activities,  so  long  as  the  causal  aljnor- 
uial  disturbance  exists.  This  organically  conditioned  state  of  psychic 
pain  is  psychologically  augmented  by  other  simultaneous  disturb- 
ances of  the  psychic  mechanism,  largely  arising  out  of  the  painful 
depressi^on  (comp,  page  49). 

These  accessory  sources  of  pain  are  found  in  unpleasant  apper- 
(^eption  of  the  external  world  in  the  mirror  of  the  painfully  altered 
consciousness  (psychic  dysesthesia) ;  in  the  feeling  of  being  over- 
whelmed which  the  patient  experiences  in  his  psychic  mechanism; 
and  finally  in  the  consciousness  of  inhibition  which  all  psychic  activ- 
ities thus  undergo  (ideation,  desires).  The  most  painful  thing  for  the 
patient  at  the  height  of  the  disease  is  the  absence  of  both  pleasant 
and  unpleasant  emotional  coloring  of  ideas  and  sense-perceptions 
(psychic  anesthesia). 

The  general  result  of  these  painful  psychic  processes  expresses 
itself  clinically  in  depression  and  sadness.  Psychic  dysesthesia  causes 
the  patient  to  be  retiring,  with  desire  to  avoid  people,  or  to  assume 
a  hostile  attitude  toward  the  external  world;  psychic  anesthesia 
causes  indifference,  even  to  the  most  important  things  of  life. 

Along  with  the  disturbance  of  content  there  is  a  change  (for- 
mal) in  the  sphere  of  emotional  life.  This  is  manifest  in  the  fact 
that  ideas,  as  well  as  sense-perceptions,  are  accompanied  with  ex- 
tremely vivid  unpleasant  feelings,  which  may  attain  the  degree  of 
affects,  while  at  the  same  time  the  threshold  of  excitability  of  emo- 
tion lies  abnormally  deep. 

Thus  it  may  happen  that  every  mental  act,  even  sense-percep- 
tions, may  be  accompanied  by  intense  feelings  of  displeasure  (psychic 
hyperesthesia). 

Such  states  of  psychic  hyperesthesia,  like  phenomena  observed 
where  nerves  are  affected  with  neuralgia,  precede  those  of  psychic 
anesthesia,  or  they  alternate  with  the  latter. 

The  affective  states  thus  produced  express  themselves  in  feelings 
of  displeasure  or  sadness,  which  may  be  intensified  to  despair;  or  in 
feelings  of  surprise  (embarrassment,  confusion,  astonishment,  fright, 
shame)  or  emotional  states  of  apprehension  (anxiety,  oppression, 
fear).  This  abnormal  excitability  expresses  itself  clinically  in  irri- 
tability, sensitiveness,  and  moodiness,  since  hyperesthesia  and  anes- 
thesia alternate  and  differ  in  intensity. 


OS8  SPECIAL  PATlKn.Or.Y  AND  TlTEPArY  OF  IXSAXITV. 

The  mental  need  of  quiet  in  the  patient  is  expressed  in  retiring 
from  society  and  seeking  isolation;  the  avoidance  of  sense-impres- 
sions and  emotional  activities. 

Disturbances  in  the  intellectual  domain  are  partly  those  of  form 
and  partly  those  of  content.  The  former  consist  of  retardation  of 
thought  and  slowness  of  the  association  of  ideas. 

This  retardation  is  part  of  the  general  slowing  of  psychic  activ- 
ities; in  part,  too,  dependent  upon  the  painful  feelings  with  which 
every  psychic  act  is  colored. 

The  inhibition  of  the  free  course  of  ideas  is  an  important  ac- 
cessory source  of  psychic  pain.  This  expresses  itself  clinically  in  a 
feeling  of  fatigue,  of  mental  vacuity,  and  of  lessened  mental  energy 
(stupidity,  lack  of  memory  of  which  so  many  patients  complain). 
Temporary  complete  stoppage  of  thought  induces  despair.  The  dis- 
turbance in  the  association  of  ideas  is  essentially  due  to  the  fact  that 
only  such  ideas  are  possible  as  are  in  accord  with  the  painful  feeling, 
and  thus  the  sum  of  the  ideas  that  can  possibly  be  reproduced  is 
limited  to  those  of  painful  content.  Inhibition  and  disturbed  associa- 
tion favor  the  occurrence  of  imperative  ideas. 

Formal  disturbances  of  ideas  occur  in  all  melancholies.  They 
may  be  the  only  anomalies  (melancholia  without  delusions) ;  fre- 
quently, however,  there  is  disturbance  in  the  content  of  ideas:  de- 
lusions. 

In  the  great  majority  of  cases  these  arise  psychologically  and 
are  an  attempt  to  explain  the  abnormal  state  of  consciousness;  but 
the  delusion  is  not  necessarily  the  product  of  a  logical  conscious 
operation  of  thought;  it  may  also  be  merely  the  conscious  result 
of  an  unconscious  product  of  association.  Delusions  arising  out  of 
errors  of  the  senses  are  infrequent  in  melancholia,  and  pure  primor- 
dial delusions  are  still  more  infrequent. 

The  content  of  melancholic  delusions  is  extremely  varied,  for 
they  include  all  varieties  of  human  trouble,  care,  and  fear.  Since 
they  are  ahvays  created  out  of  the  ideas  peculiar  to  the  individual,  it 
is  natural  that  they  should  vary  infinitely  according  to  individual  en- 
dowment, sex,  position,  education,  and  age,  even  though  certain 
constant  cares  and  fears  of  the  human  race  lend  to  the  delusions  of. 
innumerable  melancholies  of  all  races  and  all  times  certain  features 
and  characteristics  of  content  which  are  alike  (Griesinger). 

The  common  character  of  all  melancholic  delusions  is  that  of 
suffering,  and,  in  contrast  with  the  similar  delusions  of  paranoia  with 
delusions  of  persecution,  they  are  referred  to  personal  guilt. 


PSYCHONEUKOSES— PRIMARY  CURABLE  STATES.  289 

Errors  of  the  senses  are  very  frequent  in  the  course  of  the 
severer  forms  of  melancholia. 

Just  as  the  content  of  the  ideas  in  melancholia  are  hostile  and 
painful,  so,  too,  are  the  delusions  frightful.  In  affective  states,  espe- 
cially where  they  are  of  the  nature  of  an  anxious  apprehension,  errors 
of  the  senses  are  especially  intense  and  frequent. 

The  peculiar  inhibition  of  the  psychic  activities  in  melancholia 
expresses  itself  with  especial  clearness  on  the  psychomotor  side  of 
mental  life. 

The  intensification  of  mental  pain  by  every  kind  of  mental 
activity  causes  laziness,  avoidance  of  work,  neglect  of  occupation, 
and  inclination  to  retire  and  take  to  bed.  The  want  of  self-confidence 
makes  the  attainment  of  ambition  seem  impossible  and  destroys  all 
effort.  The  inhibited  psychic  activity  in  itself,  the  difficulty  of 
change  of  ideas  and  their  coloring  by  unpleasant  feelings,  the  loss  ol: 
mental  interests  which  incite  to  act,  find  their  expression  in  the  com- 
plaints of  the  patient  that  he  would  like  to  act,  but  that  he  cannot 
will  himself  to  act. 

The  painful  effect  of  the  concrete  idea  impelling  to  a  volun- 
tary act,  due  to  contrasting  ideas  arising  out  of  the  greatly  dimin- 
ished sense  of  self,  consciousness  of  defective  power,  psychic  power- 
lessness,  and  the  possibility  that  an  idea  may  be  sufficient  to  prevent 
success,  cause  the  patient  to  vacillate  between  impulses  and  inactivity, 
expressed  clinically  in  the  vacillation  and  want  of  decision  that 
characterize  such  patients. 

The  fundamental  character  of  melancholia  is  that  of  absence  of 
energy :  passiveness.  However,  in  such  cases,  at  least  episodically,  a 
very  stormy,  violent  activity,  going  even  to  the  extent  of  furor,  is 
possible.  This  is  explained  by  the  fact  that  temporarily  the  inhibi- 
tion is  overcome  by  intense  emotion. 

Other  ÜSTervous  Symptoms. — In  all  melancholies  at  the  begin- 
ning and  at  the  height  of  the  disease  sleep  is  interfered  with.  It  may 
be  absent  entirely  or  disturbed  by  frightful  dreams  and  frequent 
awakening;  or  the  patients  feel  that  though  they  sleep  they  are  not 
refreshed  and  strengthened  as  others  are  by  normal  sleep. 

Headache  is  frequent,  especially  in  the  anemic.  The  patients 
often  complain  of  a  feeling  of  emptiness  or  pressure  in  the  head, 
partly  due  to  paralgias,  partly  as  allegoric  expressions  of  the  psychic 
inhibition.  General  bodily  feeling  is  disturbed;  the  patients  feel 
tired,  depressed,  uncomfortable;  and  this  diminution  of  vital  energy 
finds  its  classic  expression  in  the  relaxed  attitude ;  in  the  diminished 
duration  of  muscular  activity;  in  the  hesitating  movements  and  slow 


J?00  SPECIAL  rATHOLOriY  AND  TIIKRAPY  OF  IXSAXITV. 

speech;  and  in  the  atouicity  and  weakness  oi'  the  niuselcs.  Besides 
the  psychic  elements  (diminished  self-confidence,  etc.)  here  opera- 
tive, this  weakness  of  innervation  seems  to  depend  npoa  disturbed 
vital  sensibilities  and  altered  muscular  feelings  (heaviness,  tender- 
ness). 

Sensory  disturbances  are  often  present.  Paresthesias  and  anes- 
thesias are  more  frequently  met  than  paralgias,  hyperesthesias,  and 
neuralgias;  and  they  aggravate  the  emotional  condition,  induce 
affects,  and  favor  the  occurrence  of  allegoric  delusions.  The  secre- 
tions are  diminished,  as  are  all  the  instinctive  impulses. 

This  is  especially  noticeable  with  reference  to  food,  Avliich  not 
infrequently  is  positively  refused.  Along  with  delusions  and  errors 
of  the  senses  as  a  cause,  frequently  the  refusal  of  food  is  due  to  want 
of  appetite  and  constipation  as  physical  causes. 

Too,  even  though  food  is  not  refused,  the  state  of  nutrition  is 
much  reduced.  Progressive  loss  of  weight  and  anemia  are  always 
observed,  and  in  part  may  be  referred  to  the  involvement  of  trophic 
nerve-centers.  The  disturbance  of  vasomotor  innervation  is  im- 
portant. In  the  majority  of  patients  the  arteries  are  contracted. 
The  pulse  is  small  and  the  artery  feels  like  a  wire. 

The  phenomena  due  to  this  condition,  aside  from  the  arrest  of 
the  secretions,  are  lessened  turgor  vitalis;  dry,  hard  skin  with  scaly 
desquamation;  cold  extremities,  with  possibly  venous  stasis  and 
edema.  Thus  the  patients  look  much  older  than  they  actually  are. 
The  temperature  is  usually  subnormal;  respiration  is  superficial  and 
incomplete,  even  though  quickened  by  the  emotion  of  fear.  The 
pulse-rate  varies ;  at  the  height  of  apprehensive  excitement  it  is  de- 
cidedly increased. 

Melancholic  insanity  manifests  itself  clinically  in  two  definite 
forms,  which  may  be  called  simple  melancliolia  and  melancholia  ivith 
stupor,  and  they  demand  separate  description. 

I.  Simple  Melax^cholia. 

The  milder  cases  of  melancholia  are  those  in  which  the  symp- 
toms of  mental  inhibition  are  essential!}''  psychic,  due  to  a  con- 
scious painful  mental  process,  and  not  organically  induced  by  ar- 
rested activity  in  the  psychomotor  nervous  paths,  shown  in  its 
extreme  degree  by  distiirbance  of  muscular  innervation  (tetany,  cata- 
lepsy). In  these  cases,  too,  there  is  not  deep  disturbance  of  con- 
sciousness. The  inhibition  in  the  emotional  life  shows  itself  in 
anesthesia  with  despair;  in  the  intellectual  life,  as  painful  obstruc- 


PSYCHONEUROSES— PRIMARY  CUJIAP.LK  S'lA'lKS.  201 

tion  to  the  processes  of  thought  in  all  diroctions;  in  the  will,  as 
distressing  incapacity  to  decide  upon  an  action,  reaching  even  to  the 
extent  of  complete  arrest  of  voluntary  acts  {comp,  page  93).^  The 
necessary  result  is  a  profound  diminution  of  confidence  in  self. 

Since  the  consciousness  of  the  patient  is  a  constant  source  of 
pain,  and  since  the  patient  is  a  martyr  to  emotions  and  thoughts  of 
threatening  danger,  which  constantly  maintain  and  intensify  the 
painful  state  of  emotional  strain,  his  position  becomes  proportion- 
ately more  painful,  since  he  feels  incapahle,  or  at  least  not  capable 
at  all  times,  of  performing  the  act  that  will  deliver  or  save  him. 

The  fundamental  manifestation  of  the  disease-picture  is  passiv- 
ity: a  distressing  arrest  of  psychic  activities.  The  passivity  of 
melancholies  may  temporarily  reach  a  degree  Avhere  there  is  com- 
plete arrest  of  the  psychomotor  activities.  Kot  merely  acts,  but  even 
speech  and  movements  of  locomotion  then  become  slower  or  difficult, 
and  occur  only  in  obedience  to  intense  and  repeated  external  stimuli 
and  necessity.  They  are  later  only  begun  and  not  completed,  until 
finally  every  motor  act  has  become  impossible  (passive  melancholia). 

These  cases,  in  which  evidently  the  psychic  inhibition  is  in- 
creased and  complicated  by  augmented  organic  (moleciüar)  resist- 
ance in  the  voluntary  paths,  constitute  transitional  forms  to  the 
severer  forms  of  melancholia  with  stupor,  in  which  consciousness  is 
also  troubled  and  the  patient  sinks  into  a  cloudy  mental  state. 

Except  when  episodically  or  in  the  transition  to  stuporous 
melancholia  such  states  of  complete  mental  inhibition  occur,  the 
consciousness  of  the  patient  suffering  with  simple  melancholia  is  not 
more  profoundly  disturbed,  even  though  it  be  filled  by  painful 
images  and  ideas. 

Thought  is  interfered  with  and  limited,  but  judgment  is  possi- 
ble, in  contrast  with  stuporous  melancholia,  in  which  there  is  a 
state  of  delirious  dreaming  with  spontaneous  delusions — for  example, 
like  those  that  occur  in  the  delirium  of  fever  or  intoxication,  and 
which  undergo  no  further  combination  and  elaboration. 

Owing  to  the  fact  that  the  patient  suffering  from  simple  melan- 
cholia is  capable  of  drawing  conclusions,  there  is  the  possibility  of 
the  creation  of  delusions,  and  of  their  further  systematic  combination 
and  logical  valuation.  The  passive  attitude  of  the  patient  may  at 
any  time  change  to  a  condition  in  which  the  patient  is  continually 
excited  and  active,  and  he  obtains  relief  by  expressing  his  mental 
pain  and  state  of  emotional  tension  in  the  most  furious  way  in 
crying,  wringing  his  hands,  constant  movement  (melancholia  erra- 
bunda),  and  even  in  destructive  acts  (agitated  or  active  melancholia). 


292  SPECIAL  PATHOLOGY  AND  TJIEKAPY  OF  INSANITY. 

The  cause  of  this  state  is  not  to  be  sought  in  increased  readiness 
in  the  transformation  of  ideas  into  motor  impulse,  as  is  tlie  case  in 
mania,  but  in  the  enormous  force  with  which  the  motor  impulse  is 
present  in  consciousness,  which  enables  it  to  overcome  all  inhibition. 

The  fact  is  that  these  agitated  melancholic  states  form  only  the 
height  of  the  general  disease-picture  or  are  episodic  phenomena  in 
the  course  of  (passive)  melancholia.  These  affect-like  outbursts  of 
despair,  which  may  temporarily  overcome  the  classic  inhibition  of 
the  melancholic,  arise  out  of  tlie  painful  mental  state,  which  tem- 
]iorarily  may  become  unbearable,  and  which  depend  upon  ]isychic 
anesthesia,  hyperesthesia,  inhibition  of  thought,  imperative  ideas, 
lack  of  energy,  and  also  complicating  neuralgias,  perversions  of 
bodily  feeling  in  general,  precordial  distress,  frightful  hallucinations, 
and  delusions.  In  such  imperative  psyrhic  states  suicide  is  near.  An- 
algesia facilitates  the  act.  Frequently,  especially  under  the  impelling 
influence  of  precordial  distress,  there  are  destructive  acts  directed 
toward  others.    Psychic  dysesthesia  and  anesthesia  favor  them. 

During  such  paroxysms  the  patient  in  violent  agitation  resembles  a  case 
of  furious  mania;  indeed,  he  may  surpass  the  la,tter  in  destructiveness.  As  a 
rule,  by  inexperienced  observers  these  cases  of  depression  with  continued  ex- 
citement are  diagnosticated  as  furious  mania,  although,  between  the  de- 
structive impulse  of  the  maniac  and  the  motor  activity  of  the  depressed, 
dependent  iipon  painful  states  of  consciousness,  there  is  an  essential  difference. 

In  active  melancholia  there  may  be  even  the  rapidity  of  ideas  called  the 
flight  of  ideas;  but  here  this  phenomenon  has  entirely  a  different  character 
from  the  flight  of  ideas  that  occurs  in  mania,  as  Richarz  has  cleverly  pointed 
out.  In  spite  of  all  possible  rapidity  in  the  flow  of  ideas,  the  delirium  of 
active  melancholia  is  still  monotonous,  painful  in  conteirt,  and  moves  in  the 
narrow  circle  of  melancholic  emotions,  and  is  but  a  constant  variation  of  the 
same  theme. 

The  power  to  form  a  series  of  ideas  with  continued  and  infinite  associa- 
tions is  wanting  here,  in  contrast  with  mania,  in  which  association  of  ideas  is 
infinitely  facilitated. 

The  ideas  of  the  melancholic  are  only  fragments  of  chains  of  thouglit. 
He  is  unable  to  finish  the  train  of  thought  commenced,  which  constantly 
escapes  from  him,  and  he  is  constantly  forced  back  to  begin  again.  For  this 
reason  such  patients  complain  of  the  constant  painful  resultless  impulse  to 
think;  of  the  impossibility  of  continuing  a  train  of  thought  and  carrying  it  to 
its  logical  conclusion;  of  the  emptiness  of  consciousness  in  spite  of  the  fact 
that  it  seems  to  be  overfilled. 

It  is  therefore  with  a  certain  amount  of  justice  that  Emrainghaus 
regards  this  condition  as  an  overpowering  imperative  idea. 

Simple  meliineliolia  is  decidedly  the  most  frequent  form  of 
mental  disease.  It  presents  clinically  great  variety  in  the  grouping 
of  the  symptoms  and  the  intensity  of  the  disease.    From  this  stand- 


PS YCHONEUROSES— PRIMARY  CURABLE  STATES.  293 

point  essentially  three  degrees  may  be  distinguished,  for  a  case  may 
pass  through  them  all  or  end  at  any  one  of  them.  The  mildest  form 
of  the  disease  may  he  called : — 

(a)  Melancholia  iviÜiout  Delusion. 

The  disease-picture  is  limited  to  anomalies  of  the  feelings  and 
will,  with  disturbance  of  thought  that  is  merely  formal.  There  are 
neither  delusions  nor  errors  of  the  senses  (hallucinations  and  illu- 
sions). This  mild  form  of  melancholia  is  only  exceptionally  observed 
in  institutions  for  the  insane,  but  it  is  extremely  frequent  in  private 
practice.  Often  it  long  escapes  the  observation  of  the  laity,  as  well 
as  of  physicians,  for  the  patient  is  able  to  preserve  an  appearance  of 
calm  and  reason. 

To  be  sure,  the  somber  character,  the  irritability,  the  depression, 
and  the  change  from  the  usual  manner  of  thinking  and  feeling  are  re- 
marked; but  these  are  explained  or  attributed  to  external  causes, 
and  the  patient  who  does  not  wish  to  appear  ill  gives  all  manner  of 
excuses  for  his  carelessness  and  laziness  and  his  neglect  of  customary 
duties.  Thus,  often  for  a  long  time,  the  true  mental  condition  re- 
mains undiscovered  until  aggravation  of  the  malady,  or  some  act  of 
violence  arising  out  of  the  unbearable  painful  state  of  strain,  reveals 
it.  The  ordinary  medical  diagnosis,  overlooking  the  psychic  anomaly, 
is  frequently  limited  to  anemia,  chlorosis,  hysteria,  neurasthenia,  etc. 
The  disease  does  very  frequently  rest  upon  this  physical  and  neurotic 
foundation,  especially  in  connection  with  puberty  (homesickness)  and 
also  in  hypochondriacs,  neurasthenics,  and  constitutional  neuropaths. 
When  it  is  dependent  upon  this  hereditary  foundation,  it  is  not 
infrequently  associated  with  imperative  ideas  (murder,  suicide,  fire), 
and  also  with  somatic,  neurotic,  and  especially  sensory  functional  dis- 
turbances (paralgias,  neuralgias).  In  these  cases  the  disease  is  pro- 
tracted, of  graver  prognosis,  and  there  are  transitions  to  general 
degenerate  constitutional  melancholia — folie  raisonnante  {vide  "Psy- 
chic Degenerations"). 

Case  6. — Melancholia  without  delusion  due  to  chronic  intestinal 
catarrh  and  neurasthenia. 

Physician,  aged  31,  married,  came  asking  advice  about  an  abnormal  state 
of  feeling.  His  father  was  given  to  drink  from  his  youth;  his  vice  interfered 
with  the  happiness  of  the  family,  and  cast  a  shadow  over  the  patient's  youth, 
who  suffered  much  from  the  harsh  treatment  of  his  father,  and  he  attributed 
his  apprehensive,  retiring  character  to  this.  He  was  neuropathic,  emotional, 
blushed  readily,  was  easily  embarrassed  by  this,  and  on  accovmt  of  it  was 
often  the  object  of  ridicule  by  his  companions. 


204  ^^PKCTAL  PATHOT.O(;V  ANO  TllKRArV  OF  TXi^AXITY. 

In  the  winter  of  1SC3  he  eontraetecl  a  gastro-intestinal  catarrh  by  taking 
cold,  which  lie  neglected,  and  which  became  chronic  and  still  existed  at  the 
time  of  the  beginning  of  his  mental  disease.  The  patient  became  a  medical 
student,  studied  hard,  and  during  vacation  was  forced  to  help  his  drunken 
father  in  his  practice.  After  having  passed  his  first  examination,  he  was 
forced  to  take  up  his  father's  practice,  who  had  had  an  attack  of  apoplexy. 
Soon  after,  his  mother  fell  seriously  ill.  Along  with  the  care  of  his  patients, 
his  practice,  and  his  struggle  for  daily  bread,  the  patient  continued  to  study 
hard  at  night.  This  aggravated  the  gastro-intestinal  trouble.  The  patient 
noticed  pus  in  his  dejections,  recognized  that  his  intestinal  disease  had  finally 
gone  on  to  the  development  of  ulcers,  and  he  became  hypochondriac  and  feared 
intestinal  perforation.  In  spite  of  all  obstacles  he  passed  a  good  examination. 
He  was  forced  immediately  to  practice.  His  father  recovered,  and  resumed  his 
excesses.  This  caused  much  trouble  and  care.  In  the  fall  of  1873  the  patient 
became  engaged.  A  rich  landowner  tried  to  turn  his  fiancee  against  him.  He 
was  reported  to  be  a  drunkard  and  epileptic.  Tliis  often  depressed  liim  ex- 
tremely. 

After  having  been  engaged  two  years  his  fiancee  was  no  longer  contented 
with  the  place  where  he  lived.  There  were  reproaches.  The  patient  aban- 
doned his  good  practice  with  heavy  heart,  to  seek  a  new  one  elsewhere.  On 
accoimt  of  an  unsuccessful  operation  for  hernia  he  fell  under  the  suspicion  of 
an  unkind  colleague.  The  intestinal  trouble  grew  worse;  moodiness,  hypo- 
chondriac depression,  constipation,  disturbances  of  digestion,  and  headache  in- 
duced the  patient  to  come  to  Gratz  for  advice.  He  attended  the  psychiatric 
clinic.  In  ail  the  lectures  he  foimd  explanations  of  his  condition  and  the  sad. 
prospect  of  becoming  insane.  There  was  also  an  impleasant  letter  from  his 
fiancee  (end  of  1874).  The  patient  became  profoundly  depressed,  sleepless,  had 
precordial  distress,  vertigo,  ringing  in  tlie  ears,  and  headache;  nothing  ap- 
])eased  him  and  he  gave  liimself  to  thouglits  of  suicide.  His  fiancee  became 
reconciled.  In  May,  1875,  he  was  married.  The  patient  hoped  to  recover,  but 
on  the  wedding  journey  his  trouble  became  aggravated.  In  his  psychic 
anesthesia  he  felt  that  he  could  not  love  his  wife.  He  reproached  himself  witli 
having  made  her  unhappy,  and  at  the  same  time  he  feared  to  become  insane, 
and  had  violent  attacks  of  disgust  of  life.  The  patient  tried  opium  (0.05  to 
0.15  gram)  twice  daily.  His  condition  became  unbearable;  he  could  take  care 
of  his  practice  mechanically  as  far  as  was  necessary,  but  he  was  without 
pleasure  in  work  or  in  life,  and  he  sought  relief  from  his  mental  pain  in  pro- 
longed outbursts  of  weeping. 

The  psychic  depression  was  always  most  marked  on  waking  in  the  morn- 
ing. He  felt  tired,  depressed,  reproached  himself  with  liaving  so  lightly  mar- 
ried, and  thus  brought  unhappiness  on  his  wife  by  his  mental  breakdown. 
Later  he  began  to  fear  that  he  had  transmitted  to  his  cliild  the  seeds  of  his 
disease. 

At  his  examination  on  December  6,  1875,  the  patient  was  disturbed  and 
anxious.  He  complained  of  headache  and  pressure,  as  if  his  head  were  in  a 
vise,  and  felt  ill  and  depressed.  Cathartics  were  regularly  requii-ed;  digestion 
was  disturbed  and  the  tongue  coated.  The  patient  has  a  congested  appear- 
ance; the  pulse  was  small,  84;  extremities  cool.  He  cried  easily,  and  was 
without  courage  and  pleasure,  and  shy  of  people;  his  future  seemed  to  him 
dark. 


PSYCHONEUR0.SES— PRIMARY  CURABLE  STATES.  295 

His  diet  and  bowels  were  regulated,  and  baths  and  cold  rubbings  pre- 
scribed. Opium  was  ordered;  and  since  he  could  not  support  injections  on  ac- 
count of  his  irritable  skin,  and  his  stomach  could  not  bear  the  remedy,  it  was 
administered  in  suppositories  of  0.25  to  0.3  gram,  in  the  form  of  the  aqueous 
extract  twice  daily. 

His  condition  improved  immediately.  The  patient  was  able  to  work  more 
readily  and  to  control  the  dark  thoughts  of  the  future  and  suicide.  However, 
as  soon  as  the  efl'ect  of  the  opium  wore  oflf',  he  again  had  painful  feelings  of 
unrest,  disgust  of  life,  terrible  depression  and  apathy,  ringing  in  his  ears, 
headache,  and  anxious  feeling,  of  pressure,  as  if  his  brain  were  too  large  or  his 
skull  too  small.  Too,  simply  a  fault  of  diet,  bad  weather,  attempts  to  occupy 
himself  mentally,  or  study  of  psychiatry  immediately  induced  aggravation  of 
his  condition  with  precordial  distress  and  impulse  to  suicide.  He  could  only 
exist  with  the  aid  of  opium ;  but  even  this  comfort  made  him  anxious,  for 
occasionally  he  attended  the  medical  society  and  heard  the  morphine  habit  dis- 
cussed. Sometimes  better,  sometimes  worse,  his  condition  depending  essen- 
tially upon  the  state  of  his  gastro-intestinal  tract,  he  passed  the  summer  of 
1876,  A  sojourn  in  the  mountains,  with  a  visit  afterward  to  the  seashore,  and 
the  continued  use  of  opium,  which  was  increased  up  to  1.0  gram  daily,  finally 
brought  about  a  favorable  change.  The  gastro-intestinal  trouble  disappeared 
and  psychic  depression  diminished.  There  were  times  when  the  patient  could 
look  into  the  future  with  hope,  and  life  no  longer  seemed  to  be  a  heavy  burden. 
He  long  remained  very  emotional  and  affected  by  emotional  excitement ;  slight 
errors  of  diet  and  mental  effort  immediately  caused  a  return  of  painful  depres- 
sion, and  he  then  felt  mentally  uncertain  and  depressed,  especially  in  the  morn- 
ing, when  he  became  tired  of  life.  Opium  was  gradually  withdrawn,  and  he 
could  get  on  without  it. 

In  the  course  of  the  year  1877  the  last  symptoms  of  the  disease  disap- 
peared. His  expiession  became  free,  the  former  state  of  nutrition  was 
re-established,  and  pleasure  in  life  and  work  returned. 

This  recovery,  obtained  with  so  much  difficulty,  was  subjected  to  a 
strenuous  test,  for  his  wife  died,  and  his  child  was  specifically  infected  by 
a  nurse.     The  recovery,  however,  was  maintained. 

(h)  MelanchoUa  with  Precordial  Distress. 

Very  frequently  in  tlie  conrse  of  melancholia  without  delusions 
the  symptom-complex  of  precordial  distress  arises  temporarily,  espe- 
cially during  the  early  morning  hours ;  or  it  may  be  more  protracted 
and  occur  at  the  very  beginning  (precordial  melancholia).  In  the 
latter  case  it  is  usually  a  form  of  disease  that  is  acute  or  subacute  in 
its  course.  Precordial  distress  is  one  of  the  most  important  and 
frequent  subsidiary  manifestations  of  melancholic  states.  When- 
ever it  occurs,  it  is  a  very  grave  complication,  since  it  is  dangerous 
to  the  life  of  the  patient  or  to  others  on  account  of  the  terrible  in- 
crease of  mental  pain  and  tension,  and  the  impulses  thus  induced  to 
commit  the  act  that  will  bring  relief  or  salvation.  Such  patients 
must  never  be  left  by  themselves.    Precordial  distress  is  the  essential 


296  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

factor  in  melancholia  that  forces  the  patient  out  of  his  passivity, 
renders  him  furious  and  agitated,  or  drives  him  to  despair,  depending 
upon  the  violence  and  suddenness  with  which  the  fear  enters  con- 
sciousness. An  intense  and  powerful  outbreak  of  precordial  distres.-i 
may  cause  temporary  clonding  or  even  suppression  of  consciousness, 
and  in  a  violent  and  convulsive  way  induce  acts  as  a  reaction  to  the 
undefined  fear.  This  motor  crisis,  as  the  expression  of  an  unbearable 
state  of  mental  tension,  is  ordinarily  called  raptus  melancholicus 
{comp,  page  210).  This  may  arise  out  of  the  deepest  state  of  pas- 
sivity in  a  melancholic. 

Not  infrequently  the  actual  attack  has  been  preceded  by  aura- 
like states  in  the  form  of  depression,  irritability,  headache,  vertigo, 
]ieuralgic  and  paralgic  sensations. 

The  attack  reaches  its  acme  with  a  violent  increase  of  intensity 
when  fear  enters  consciousness.  All  psychic  processes  (apperception, 
association  of  ideas,  reproduction)  are  disturbed,  or  even  prevented 
by  the  occurrence  of  the  attack  of  fear.  The  disturbance  or  absence 
of  apperception  awakens  the  idea  that  the  world  is  merely  a  shadow; 
that  all  things  have  been  destroyed ;  thought  is  for  the  moment  en- 
tirely suspended,  or  there  is  only  a  confused  painful,  uncontrolled 
series  of  ideas,  in  which  desultory  frightful  hallucinations,  delusions 
of  general  annihilation,  destruction  of  the  world,  or  possession  by  the 
devil,  occur.  Consciousness  is  deeply  disturbed,  and  there  may  even 
be  temporary  absence  of  self-consciousness. 

Depending  on  the  intensity  of  the  attack,  the  motor  sphere  pre- 
sents the  affect  of  despair  (tearing  the  hair,  destroying  the  clothing, 
destructive  acts,  murder,  suicide,  wild  destruction  of  everything  that 
falls  into  the  patient's  hands).  The  motive  for  this  lies  in  the  ill- 
defined  impulse  to  overcome  the  state  of  psychic  tension,  and  thus 
the  analgesia  makes  possible  the  most  frightful  self -mutilations 
(Bergmann's  patient,  who  dug  out  his  own  eyes),  and  psychic  anes- 
thesia leads  to  the  most  frightful  acts  of  violence  toward  others.  At 
the  height  of  the  condition,  the  wild  destructive  acts  of  these  un- 
fortunates are  like  true  psychic  convulsions. 

Along  with  these  psychic  symptoms  there  are  remarkable  dis- 
turbances of  respiration  and  circulation.  The  respiration  is  super- 
ficial and  frequent,  and  the  heart's  action  is  accelerated  and  irreg- 
ular, the  pulse  is  small  and  quick,  the  skin  cool  and  pale,  and  the 
secretions  are  suppressed  during  the  attack.  Toward  tbe  end  of  tbe 
paroxysm  there  is  usually  a  profuse  perspiration.  The  symptoms  of 
disturbed  circulation  Justify  the  assumption  that  a  sympathetic  neu- 
rosis (vascular  spasm)  is  the  cause  of  the  attack. 


PSYCHONEUROSES— PRIMARY  CUr?A[5LE  STATES.  207 

The  attack  ceases  suddenly,  and  its  course  may  be  compared 
graphically  to  a  rapidly  rising  and  falling  curve. 

The  fear  passes  off,  and  the  patient  breathes  as  if  he  had  awak- 
ened from  a  terrible  dream,  and  feels  relieved.  According  as  the 
attack  has  been  severe  or  not,  memory  of  the  events  is  wanting  or 
only  summary.  The  duration  of  the  condition  is  from  a  few  minutes 
to  half  an  hour. 

Case  7. — Chronic  melancholia,  with  raptus  melancl;)olious,  due  to 
exhausting  causes. 

P.,  aged  57,  female  peasant,  was  admitted  to  the  asylum  September  10, 
1873;  of  healthy  family  and  having  had  no  diseases,  she  Avas  married  at  the 
age  of  19,  and  had  had  ten  children  when  she  was  40  years  old.  The  rapid  suc- 
cession of  births,  the  continued  lactation,  hard  work,  bad  food,  and  struggle 
for  existence  reduced  her  physical  strength.  IVom  year  to  year  she  grew 
weaker  and  thinner,  and  work  became  constantly  more  painful.  In  18G1  she 
fell  sick  with  typhoid  fever;  her  convalescence  was  prolonged,  because  she  had 
to  resume  work  immediately  and  her  food  was  insufficient.  From  this  time 
there  was  great  irritability,  sensitiveness,  and  anemia.  The  patient  stated 
that  thereafter  every  winter  she  had  an  attack  of  depression  lasting  several 
weeks.  Violent  attacks  of  melancholia  occurred  in  1865  and  in  1868,  said  to 
have  been  the  result  of  fright  and  emotional  excitement.  At  that  time  she 
was  sad,  avoided  work,  anxious,  afraid,  and  thought  she  was  followed,  con- 
demned to  hell,  and  that  her  future  was  filled  with  frightful  sufferings.  The 
ordinary  treatment  of  the  country  physician  where  she  lived  was  applied  in 
the  form  of  purgatives,  the  application  of  irritating  ointment,  and  similar 
things,  as  result  of  which  the  patient  was  still  more  physically  enfeebled,  and 
her  mental  condition  aggravated.  The  state  of  anxious  excitement  and  the 
delusions  arising  out  of  it  passed  ofl"  in  time,  but  the  patient  remained  sad, 
depressed,  and  irritable,  and  took  no  pleasure  in  work  or  life.  She  slept  badly, 
had  little  appetite,  and  was  badly  nourished  and  anemic.  In  March,  1873, 
there  was  still  further  reduction  of  nutrition,  and  edema  of  the  feet. 

Her  habitual  mental  depression  quickly  increased  to  a  decided  degree. 
Soon,  on  waking  in  the  morning,  she  had  attacks  of  horrible  distress  in  the 
region  of  the  heart.  She  felt  as  though  a  great  stone  lay  on  her.  Then  she 
broke  out  in  perspiration  and  moved  wildly  about.  Tbese  morning  attacks  of 
distress  became  more  and  more  violent,  until  she  lost  her  senses.  She  then 
thought  that  she  was  in  hell,  and  she  felt  as  if  she  had  been  thrown  doAvn  from 
a  great  height  and  was  floating  aboiit  in  the  air.  Everything  she  saw  was 
fiery  red  or  white.  She  thought  that  the  world  had  come  to  an  end,  and  by 
her  fault,  and  that  it  would  soon  be  her  turn.  At  the  same  time  she  felt  a 
horrible  confusion  of  thought,  in  which  her  ideas  became  completely  mixed. 
At  the  height  of  the  attacks  of  distress  she  Avas  disgusted  with  life  and  im- 
pelled to  destructive  acts.  Driven  by  despair,  she  then  rushed  about  the  room, 
biting  and  striking  others  and  destroying  everything  that  fell  to  her  hand; 
this  brought  her  relief.  In  these  attacks,  which  lasted  until  noon,  it  was  cus- 
tomary to  shut  her. up  in  a  dark  room  and  tie  her. 

During  the  afternoon  she  became  freer  of  fear,  and  in  the  evening  she 
felt  no  cardiac  oppression.  During  the  period  of  relative  freedom  she  was 
simply  depressed,  had  no  feeling  of  pleasure,  and  could  not  pray. 


298  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  patient  is  of  medium  size;  the  brow  low  and  narrow.  There  is  no 
subcutaneous  fat.  The  patient  is  very  anemic;  the  heart-sounds  are  weak, 
but  pure;  the  pulse  small  and  easily  compressed;  and  the  vessel-walls  show 
but  slight  tension.  No  vegetative  distiu-bances.  The  patient  was  given  rich 
food,  wine,  iron,  and  treated  witli  injections  of  the  aqueous  extract  of  opium 
(0.15  gram  twice  daily).  The  opimu  had  an  actually  specific  effect  upon  the 
distress  and  attacks  of  excitement.  The  distress  occurred  only  in  the  morn- 
ing on  awaking,  and  soon  became  only  a  feeling  of  moderate  oppression.  The 
general  state  of  nutrition  improved  and  hope  returned..  She  became  mentally 
freer,  full  of  hoi^e,  and  could  work.  Gradually  the  opium  could  be  dispensed 
with.  Aftei"  it  had  been  suspended  for  some  time  there  was  a  recrudescence 
of  the  melancholia,  which  disappeared  in  a  few  days  when  the  opium  was  re- 
sumed. Later  attempts  to  withdraw  the  medicine  showed  that  it  could  not  be 
dispensed  with,  because  of  distress  and  sleeplessness;  but  finally  the  patient 
was  able  to  get  on  with  doses  of  from  0.02  to  0.03  gram.  With  this  she  felt 
physically  well,  only  slightly  depressed,  and  took  pleasure  in  work.  On  Sep- 
tember 30,  1S74,  the  patient  was  discharged,  with  very  sliglit  traces  of  painful 
depression  present,  and  was  instructed  to  continue  tlie  internal  use  of  opium 
for  a  time. 

(c)  MelanchoUa  with  Delusions  and  Errors  of  the  Senses. 

In  the  course  of  melancholia  dehisions  and  errors  of  the  senses 
often  occur.  Tho}"  develoj)  gradiuilly  in  the  course  of  melanchfAiOi 
without  delusion,  and  represent  the  acme  of  the  development  of  the 
disease,  or  they  occur  at  an  early  period  after  the  beginning  of  the 
depression.  This  is  the  rule  in  acute  and  subacute  cases.  Since  in 
contrast  with  the  delusions  of  primary  hallucinatory  insanity  and 
paranoia  the  false  ideas  of  melancholies  are  almost  always  the  product 
of  efforts  to  explain  the  abnormal  state  of  consciousness,  it  is  usually 
possible  to  trace  the  delusions  to  their  source:  i.e.,  to  the  funda- 
mental elementary  psychologic  disturbance. 

Thus,  the  profoundly  changed  feeling  of  self  in  the  patient, 
which  depends  either  upon  consciousness  of  the  inhibition  of  feeling 
or  upon  ideas  and  impulses,  and  which  finds  its  clinical  expression 
in  depression  and  want  of  self-confidence,  leads  to  the  delusion  of 
being  ruined,  a  beggar,  or  forced  to  die  of  starvation.  The  psychic 
dysesthesia  causes  the  external  world  to  appear  in  a  hostile  light, 
and  gives  rise  to  ideas  of  persecution  and  threatening  danger.  The 
feeling  of  inhibition  and  of  being  overpowered,  in  individuals  of 
limited  mental  power,  leads  to  the  delusion  of  being  under  the  influ- 
ence of  the  powers  of  darkness — of  being  bewitched.  Psychic  anes- 
thesia, which  destroys  all  ethic  and  humane  feelings,  leads  to  the 
delusion  that  all  human  attributes  have  been  lost,  and  of  being 
changed  into  an  animal.  On  the  religious  side,  since  comfort  in 
prayer  is  lost  and  all  relation  with  religion  is  felt  to  be  destroyed,  the 
delusion  of  being  rejected  by  God,  of  having  lost  eternal  happiness, 


PSYCHONEUROSES— PRIMARY  CURABLE  STATRS.  299 

or  of  being  possessed  by  the  devil,  easily  arises.  In  the  highest  de- 
grees of  psychic  anesthesia,  when  sensory  perceptions  no  longer  have 
any  intensity  or  emotional  coloring,  the  external  world  seems  to  be 
merely  a  shadow,  which  awakens  distressing  delusions  of  general  and 
personal  destruction. 

Precordial  distress  and  anxious  emotional  states  of  expectation 
in  general  are  very  important  sources  of  delusions.  They  give  rise 
to  the  delusion  that  some  danger  actually  threatens.  This  may  be 
individually  translated  objectively  into  ideas  of  imaginary  persecu- 
tion, threatened  death,  or  loss  of  fortune.  At  the  same  time,  on 
account  of  the  loss  of  confidence  in  self,  the  patient  easily  develop.^ 
the  delusion  of  being  a  sinner  or  a  criminal  meriting  such  punish- 
ment. As  a  further  motive  there  may  have  been  previously  an  actual 
infraction  of  the  law,  or  some  harmless  previous  act  or  neglect,  which 
to  the  hyperesthetic  conscience  appears  to  be  a  crime. 

Too,  abnormal  sensations  in  the  domain  of  the  sensory  nerves 
(paralgias,  neuralgias,  anesthesias)  and  anomalies  of  taste  and  smell 
may  be  the  cause  of  the  creation  of  allegoric  false  ideas.  Errors  of 
the  senses  constitute  another^ abundant  source  of  delusions.  All  the 
senses  may  be  affected  simultaneously  and  temporarily  place  the 
patient  in  an  imaginary  world. 

A  patient  plunged  into  an  anxious  state  of  emotional  apprehension  hears 
voices  that  announce  a  threatened  catastrophe,  death,  imprisonment,  or 
damnation  of  his  soul.  The  external  world  appears  to  him  hostile,  and  insig- 
nificant words  or  noises  change  for  him  into  threats,  insults,  ridicule,  or 
mocking  laughter. 

Too,  the  visions  of  such  patients  are  frightful.  They  see  themselves  sur- 
rounded by  ghosts  and  devils;  the  executioner,  who  waits  for  them;  murdei'- 
ers,  who  threaten  them.  Gustatory  hallucinations  lead  to  the  delusion  that 
there  is  poison  in  the  food  or  that  it  is  unclean.  Olfactory  hallucinations 
bring  up  the  idea  of  being  surrounded  by  corpses,  or  being  in  the  sulphur 
fumes  of  hell ;  neuralgic  and  paralgic  sensations  give  origin  to  the  delusion  of 
being  martyred  or  persecuted  by  evil  spirits. 

By  the  addition  of  delusions  and  errors  of  the  senses,  the  pas- 
sivity may  be  still  further  intensified  in  accordance  with  their  con- 
tent. For  example,  the  patient  hears  voices  that  say  that  if  he  move 
he  will  be  lost,  or  he  sees  himself  surrounded  by  abysses;  or  the 
passivity  may  be  changed  to  a  reaction  of  despair  and  manifest  itself 
in  raptus  melancholicus  or  in  agitated  melancholia. 

Case  8. — Agitated  melancholia;  good  result  from  treatment 
with  opium. 

K.,  wife  of  an  official,  aged  30,  admitted  May  14,  1875.  Father  was 
choleric.    Her  mother  and  her  sister,  as  well  as  her  brother,  were  intensely 


300  SPECTAL  PATITOLOGY  AND  THEEAPY  OF  INSANITY. 

neuropathic  persons.  The  patient,  whose  skeleton  was  slightly  rachitic  from 
childhood,  was  feeble,  neuropathic,  and  very  impressionable.  She  was  a  sleep- 
walker, suffered  with  nightmare,  had  very  intense  dreams,  and  while  still  a 
young  girl  was  subject  to  imperative  ideas,  such  as  that  during  sleep  she 
might  strangle  herself,  as  a  resiilt  of  which  she  carefully  put  all  bands  away; 
she  also  felt  the  impulse  to  jump  out  of  the  window. 

At  13  puberty  came  on  with  chlorotic  and  hysteric  symptoms.  Her  ex- 
cited imagination  and  exalted  natiue  became  intensified.  She  wished  to  be- 
come an  actress,  and  tried  it;  but  her  nervous  excitement  made  it  necessary 
for  her  to  abandon  the  profession.  She  was  married  at  25.  Her  happy  mar- 
riage was  two  months  later  disturbed  by  the  suicide  of  her  mother-in-law. 
Evil  tongues  attributed  this  to  the  patient,  although  an  incurable  disease  had 
driven  the  mother-in-law  to  the  act. 

The  patient  became  pregnant;  to  the  trouble  arising  out  of  gossip  was 
added  sorrow  at  the  death  of  two  friends  of  tlie  family.  In  February,  1871, 
her  child  was  born  with  difficulty,  and  had  harelip  and  cleft  palate,  and,  with 
sickness,  added  much  to  the  mother's  care. 

In  1S73  the  sensitive  wife  learned  that  her  liusband's  relatives  spoke  dis- 
paragingly of  her,  and  said  that  he  might  have  made  a  better  match.  This 
lemark  made  a  deep  impression  on  her,  and  she  souglit  to  find  out  whether  it 
was  well  foimded  and  whether  her  husband  was  actually  in  sympathy  with 
her.     She  became  shy  and  wrapped  up  in  her  depressing  thoughts. 

In  January,  1875,  she  fell  sick,  with  her  husband  and  child,  of  diphtheria. 
In  February  she  had  acute  articular  rheumatism.  After  that  she  was  feeble 
and  anemic.     Her  nervousness  was  increased  by  repeated  thefts  in  her  house. 

The  patient  felt  fatigued  and  still  excited.  She  became  suspicious  and 
easily  hurt.  She  felt  more  and  more  unworthy  of  her  husband,  and  lost 
pleasure  iii  her  child  and  life;  thought  that  her  husband  had  been  made 
imhappy  by  her,  and  that  she  must  make  the  sacrifice  and  commit  suicide  in 
order  to  free  him.     Still  she  felt  too  weak  to  perform  the  deed. 

She  was  sleepless  at  night,  and  precordial  distress,  painfiü  palpitations, 
and  loss  of  appetite  came  on.  She  could  see  no  one,  and  kind  advice  hurt 
her.  She  felt  despised,  confessed  that  she  Avas  a  thief,  the  worst  of  mothers,  a 
disgrace,  not  worthy  to  be  on  earth,  and  unworthy  of  the  best  of  all  husbands. 
Only  death  at  the  executioner's  hand  could  atone  for  her  crime.  When  her 
husband  forced  her  to  go  out  she  noticed  that  everybody  stared  at  her  and 
expectorated  before  her.  She  thought  it  her  duty  to  rid  her  husband  of  her- 
self. She  tried  to  escape  and  drown  herself;  to  stab  herself  with  a  carving 
knife;  the  sad  expression  of  those  about  her  she  took  to  be  contempt.  Be- 
cause the  physicians  would  not  give  her  poison,  she  tried  to  strangle  herself. 
^Vhen  she  was  not  successful,  she  broke  in  the  closet  for  arms  or  a  dagger 
with  which  to  kill  herself.  Unsuccessful  in  this  also,  she  threw  herself  against 
the  broken  glass  and  plunged  a  needle  into  her  breast.  Put  in  bed,  she 
thought  she  saw  the  preparations  for  her  execution  in  the  next  room;  that 
she  had  been  the  cause  of  all  the  misfortune  in  the  world.  She  greeted  the 
physician,  who  dressed  her  wounds,  as  her  executioner.  When  she  was  given 
something  to  drink,  she  thought  she  had  drunk  the  heart-blood  of  her  hus- 
band and  child.  Her  joui-ney  to  the  hospital  she  thought  wa.s  to  her  execu- 
tion, and  she  believed  that  she  first  had  to  hang  her  relatives  and  then  she 
would  be  executed. 


PSYCHONEUROSES— PRIMARY  CURABLE  STA'I'ES.      ?,0] 

On  admission  the  patient  was  frightfully  restless  and  in  apprehensive 
exeitcment.  She  tried  to  strangle  and  bite  herself,  so  that  she  had  to  be 
■watched  unremittingly. 

She  was  profoundly  overcome;  anemic;  piüse,  12G;  intercostal  neu- 
ralgia; constipation.  She  complained  of  frightful  fear;  said  she  was  a  disgrace 
and  a  streetwalker. 

Treatment  with  aqueous  extract  of  opium  subcutaneously  (0.05  to  0.1 
gram)  twice  daily  brought  sleep  and  calmed  the  excitement  in  a  few  days. 
The  patient  complained  that  the  injections  made  her  too  cowardly  to  commit 
suicide,  and  yet  that  was  her  only  way  of  escape. 

The  anxiety  and  painful  apprehensive  emotional  state  and  the  delusions 
based  on  these  grew  less  intense.  She  declared  then  that  she  was  a  sinner, 
and  demanded  to  be  sent  to  a  place  of  punishment. 

As  early  as  June  2d  the  patient  became  remarkably  free  and  began  to 
employ  herself,  to  ask  for  her  relatives,  with  doubts  that  they  were  alive. 
The  genuineness  of  a  letter  from  her  hnsband  was  doubted.  Tlie  patient  ate 
and  slept  well.  Her  general  condition  improved  and  the  pulse  fell  to  90. 
Toward  the  end  of  June  there  Avere  indications  of  an  understanding  of  her 
disease.  A  visit  from  her  husband  the  2d  of  July  had  a  favorable  effect,  and 
she  gained  complete  insight  into  her  disease.  With  gradual  withdrawal  of  the 
opium,  convalescence  continued  iindisturbed.  On  August  10,  1875,  she  wa.s 
discharged  recovered.  Memory  of  her  disease  was  like  that  of  a  horrible 
dream.  She  had  only  summary  recollection  of  the  height  of  the  disease.  The 
following  taken  from  her  recollections  may  be  mentioned: — 

"I  was  always  expecting  that  they  Avere  coming  to  take  me  to  my  exe- 
cution, and  I  heard  horrible  things.  I  thought  that  my  child  and  my  relatives 
had  been  Avliipped,  and  I  heard  the  most  terrible  accusations  cast  in  my  face. 
I  confessed  myself  guilty  of  everything  and  awaited  my  end  at  the  hands  of 
the  executioner,  since  neither  by  beating  my  head,  holding  my  breath,  or 
stopping  my  mouth  could  I  escape  a  disgraceful  death  on  the  scaffold.  I 
thought  I  Avas  branded  by  the  injections,  and  I  retained  this  idea,  as  Avell  as 
that  of  my  infinite  unAvorthiness,  a  long  time.  Everything  that  Avas  said 
around  me  I  thought  referred  to  me,  and  the  noises  of  the  pump  at  the  spring 
I  thought  Avere  occasioned  by  the  erection  of  the  guillotine.  The  cries  of  pa- 
tients I  took  for  the  noise  of  the  croAvd  that  had  assembled  to  shame  and 
maltreat  me  on  my  Avay  to  the  scaffold.  The  roaring  and  hissing  in  my  head, 
as  Avell  as  a  cold  feeling  that  sometimes  came  over  me,  I  took  for  forebodings 
of  desired  death.  Later  I  thought  I  had  been  given  up  by  my  husband  and 
family,  until  finally  insight  came  that  all  this  was  but  the  vagary  of  my  over- 
strained mind  and  nervous  system.  The  sight  of  my  husband  removed  my 
last  doubt." 

Among  the  delusions  of  melancholia,  it  is  practical  and  not  with- 
out value  to  emphasize  certain  forms  of  delusions  that  are  especiall}^ 
striking  and  frequently  observed.  The  following  clinical  forms  may 
be  mentioned : — 

1.  Religions  Melancholia. 

A  patient  naturally  religious  that  has  fallen  a  victim  to  melan- 
cholia takes  refuge  from  his  depression  and  fear  in  prayer.     The 


305  SPECIAL  rATIIOLOOY  AND  THERAPY  OF  INSANITY. 

I'ailui'e  to  obtain  the  iipliftintr  and  comforting  feeling  that  prayer 
forniorly  gave  makes  prayer  seem  ineft'ectuah  The  patient  realizes 
this  with  liorror,  and  falls  into  despair.  He  sees  that  he  is  aban- 
doned by  (lod,  and  has  lost  eternal  happiness.  He  deserves  this  fate 
because  lie  is  a  sinner,  has  prayed  too  little,  and  not  lionored  God 
enongh. 

In  the  further  course — especially  in  unedmnled  individuals,  for 
whom  the  loss  of  heavenly  grace  is  synonymous  with  falling  into  hell 
and  the  hands  of  the  devil,  as  an  expression  of  the  elaboration  of  the 
delusional  state — the  subjects  come  to  think  themselves  possessed  by 
the  devil  (demoniac  melancholia).  Neuralgias,  paralgias,  cranips, 
especially  frequent  upon  an  hysteric  foundation,  prove  that  the  vile 
body  has  been  seized  by  the  evil  spirit.  These  sensatimis  are  alle- 
gorically  interpreted.  Por  example,  intercostal  neuralgia  is  attrib- 
uted to  elTorts  of  the  devil  to  tear  out  the  heart.  Anesthesia  and 
paresthesia  show  that  the  heart  has  been  removed  and  replaced  by 
stone.  Paralgic  burning  sensations  in  the  skin  and  throat  are  inter- 
preted as  the  flames  of  hell,  etc. 

Frequently  the  demoniac  delusion  is  conceived  Avith  the  first 
occurrence  of  a  sensation  (for  example,  globus,  paralgia).  Hallucina- 
tions aid  (visions  of  evil  spirits,  odor  of  sulphur,  voices  saying  "now 
thy  soul  is  mine,"  etc.).  At  the  height  of  demoniac  delusions,  and 
as  a  reaction,  there  may  be  outbursts  of  despair,  raptus,  or  convul- 
sions that  are  interpreted  in  the  demoniac  sense  as  a  personality  that 
has  penetrated  the  body  and  controls  its  movements.  The  subsidence 
of  the  demonomania  takes  place  nsually  through  a  stage  of  religious 
melancholia,  which  may  finally  end  by  passing  through  a  stage  of 
nostalgic  melancholia. 

Case  9. — Eeligious  melancholia. 

B.,  female,  a<iecl  28,  sinjjle.  teacher,  was  admitted  July  31,  1875.  Her 
mother  is  extremely  hysteropathic.  The  patient  was  always  nervous,  easily 
frightened,  sensitive,  well  endowed,  but  of  retiring  disposition.  Aside  from 
small-pox  in  her  twentieth  year,  she  had  had  no  diseases  worth  mentioning. 

In  September,  1873,  she  was  terribly  frightened  during  the  menses,  which 
ceased  immediately,  and  returned,  after  two  months,  profusely  and  Avith  pain. 
At  the  same  time  she  suffered  with  a  feeling  of  heaviness  and  trembling  in  the 
lower  extremities,  cold  feet,  and  fluxions  to  the  head.  In  February,  1874,  she 
was  subjected  to  all  kinds  of  excitement  in  becoming  engaged  and  giving  up 
her  profession.  She  had  pains  in  the  back  of  her  head  and  disturbances  of 
circulation   (fluxions  to  the  head  and  ice-cold  extremities). 

In  March  deep  mental  depression  was  added.  The  patient  complained  of 
sad  thoughts,  became  sleepless,  and  the  world  seemed  to  her  empty.  She 
could  take  no  pleasure  in  anything  nor  pray.  This  psychic  anesthesia  was 
referred  to  unworthiness  in  confession  and  communion,  and  she  looked  upon 


PSYCHONEUROSES— I'HQrARY  CURABLE  STATES.  303 

her  condition  as  a  punishment  by  God  for  her  triviality.  Siie  thought  she  was 
damned  by  God  and  threatened  with  loss  of  her  reason.  This  discovery  was 
followed  by  outbreaks  of  desperation,  which  later  changed  into  silent  resigna- 
tion and  despair  in  blooding  over  her  lost  happiness  and  soul.  At  times,  and 
regularly  during  the  menses,  there  were  attacks  of  fear  in  which  she  heard 
that  she  was  damned  and  cast  out,  and  she  cursed  herself,  and  those  about  her 
appeared  to  her  in  changed  form  and  color,  especially  like  unto  the  devil.  She 
made  attempts  at  suicide. 

She  broke  her  engagement.  She  was  so  irritable  with  lier  parents  that 
she  broke  out  in  anger  against  them  if  they  did  not  leave  her  in  peace;  sleep 
and  nutrition  sufl'ered.  Her  treatment  was  most  unfortunate,  for  the  family 
surrounded  the  patient  kneeling  in  prayer.  Exorcisms  were  practiced :  a 
priest  pretending  to  know  something  of  psychiatry  advised  and  influenced  the 
patient,  took  her  about  in  the  country,  and  she  was  treated  homeopathically. 

At  the  time  of  her  admission,  the  patient,  of  medium  size,  was  much  re- 
duced in  general  condition,  profoundly  disturbed,  with  distorted  features  and 
lowered  head.  The  pulse  was  small,  the  extremities  cool,  the  breathing  fre- 
quent and  superficial.  Her  hands  trembled,  and  the  tongue  was  coated;  no 
neuralgia ;  uterus  small  and  in  slight  anteversion.  The  patient  was  in  a  state 
of  great  unrest  and  fear,  and  asked  that  she  should  be  left  in  peace,  saying 
that  her  body  was  healthy,  but  her  soul  dead.  In  her  great  contempt  for  self 
she  wished  no  longer  to  be  called  by  name,  but  by  number.  She  gave  herself  up 
to  infinite  self-accusations.  She  had  failed  in  confession,  had  concealed  her 
pride  and  vanity;  sinned  in  evilness  of  spirit  and  sinfully  partaken  of  the 
sacrament;  shamed  God  and  committed  divine  theft;  now  her  soul  is  to  suffer 
until  her  body  dies.  It  is  to  be  gradually  eaten  away  until  the  day  of  atone- 
ment. Her  soul  burns  like  a  red-hot  iron  in  her  body.  Divine  judgment  is  on 
her.  The  soul's  anger  has  broken  forth  in  her.  She  lives  in  constant  hate 
and  anger;  cursed  be  the  day  she  was  born!  Every  breath  and  every  pulse- 
beat  are  her  sin  and  punishment. 

The  mental  condition  at  the  height  of  the  disease  will  be  best  illustrated 
by  an  extract  from  Avhat  she  wrote  to  the  physician:  "You  looked  for  an 
insane  person  in  me  in  vain.  Unholy  and  self-confessed,  the  most  frightful 
divine  judgment  represents  the  condition  of  my  guilty  punished  soul.  I  am 
and  remain  the  only  being  of  the  whole  human  race  that  has  from  childhood 
transgressed  ail  human  and  divine  laws  in  unnatural  mental  pervej'sion  and 
wickedness,  and  I  should  be  thrown  into  the  deepest  abyss.  Fear  of  humanity 
and  false  shame  pushed  me  down  farther  and  farther;  so  that,  instead  of 
grace  and  invisible  divine  help,  I  received  only  signs  of  the  increase  of  sin  and 
punishment.  With  the  aspect  of  childish  innocence  I  became  a  godless 
monster  that  so  long  committed  divine  theft  that  the  measure  became  full; 
that  now  the  punishment  and  suffering  of  the  soul  and  the  feeling  of  eternal 
punishment  and  eternal  death  are  so  great  that  I  can  no  longer  conceal  them. 
Helpless  and  abandoned,  since  in  secret  I  have  sacrificed  only  to  vice,  noAv  my 
cursed  body  has  become  helpless  and  always  dominated  by  the  law  of  punish- 
ment. Salvation  has  become  forever  impossible,  for  all  the  necessary  human- 
ity has  been  taken  out  of  my  body  and  soul.  I  wish  to  remain  here  (asylum) 
in  order  to  pass  my  earthly  life  where  there  are  so  many  unfortunate  and  self- 
accused  punished  beings.  All  is  lost  on  me.  Give  your  medicines  to  those  who 
ask  for  them  and  who  need  them;    but  for  me,  who  have  destroyed  the  happi- 


304  SPECIAL  TATUOLOGY  AND  TITER APY  OF  INSANITY. 

ness  of  my  relatives  and  raj-self,  show  me  some  dark  place  of  despair  wlioro  I 
may  remain  until  my  frightful  body  has  gone  into  decay.  I  need  no  care  and 
attention,  for  the  godless  can  only  be  looked  on  with  repugnance,  and  escape 
from  eternal  judgment  is  impossible." 

The  psycliic  hyperostlicsia  and  frequent  attacks  of  precordial  distress 
made  treatment  -with  opium  seem  desirable.  Lukewarm  baths,  rubbing,  and 
iron  were  prescribed. 

^\  lien  subcutaneous  doses  twice  daily  of  0.15  to  0.2  gram  were  reached 
the  patient  became  quieter,  more  resigned,  slept  well,  and  her  general  condition 
improved.  She  began  to  wash  herself  again,  and  have  care  of  her  toilet.  It 
was  even  possible  to  distract  her  by  occupation.  Her  delusions  became  less 
apparent,  and  her  outbreaks  of  despair  Avhich  recalled  them,  and  in  which  she 
demanded  to  be  put  in  prison  and  doubted  her  reconciliation  with  God,  oc- 
curred less  frequently,  and  tinally  only  at  the  time  of  the  menses.  The  menses 
occurred  always  with  pain  in  the  back  and  abdomen.  There  was  frcijuently, 
too,  intercostal  neuralgia,  which,  however,  was  not  mentally  interpreted,  with 
boring  pain  in  the  occipitiil  region  and  feelings  as  if  the  cranium  were  wanting, 
tliough  without  any  demunstrable  anesthesia. 

In  the  course  of  the  year  1876  decided  improvement  continued.  The 
patient  was  still  for  a  lung  time  distressed  of  expression  and  depressed,  not 
wishing  to  mingle  with  others.  She  had  a  horror  of  religion  and  her  relatives, 
and  doubted  the  grace  of  God;  but  finally  it  was  possible  to  bring  her  into 
relation  with  her  relatives.  The  patient  did  services  for  other  patients,  and 
it  was  possible  to  bring  her  into  social  relation  with  others.  She  had  recov- 
ered physically  at  the  end  of  1870,  and  opium  had  then  been  withdrawn  for  a 
long  time.  At  the  beginning  of  1877  she  showed  insight  into  her  disease,  but 
she  still  had  great  aversion  for  church  and  religion,  and  was  afraid  of  return- 
ing into  society.  Finally  this  last  trace  of  disease  disappeared.  She  returned 
to  her  family  recovered,  April  2,  1877,  and  she  has  become  reconciled  with  God 
and  the  world. 

2.  Uypodioiulyiac  Melancholia. 

In  many  cases  of  melancholia  the  attention  of  the  depressed 
patient  is  attracted  and  directed  to  his  own  body  by  disturbances  of 
general  sensibility.  Then  the  patient  readily  finds  the  reason  for 
his  depression  in  his  bodily  sensations,  thovigh  these  are  only  acces- 
sory symptoms,  and  not  causes  of  his  melancholic  depression.  Thus, 
just  as  in  other  varieties  of  melancholia,  delusions  arise  out  of  at- 
tempts to  explain  the  abnormal  processes  in  consciousness,  which, 
hoAvever,  in  this  case  are  not  brought  into  false  relation  with  the 
external  world,  but  become  delusional  conceptions  of  physical  condi- 
tions and  processes.  This  hypochondriac  aspect  of  the  disease- 
picture  of  melancholia  arises  very  easily  whenever,  as  an  underlying 
cause  or  complication,  there  is  gastro-intestinal  or  sexual  disease. 
Another  common  form  in  which  hypochondriac  melancholia  is  clin- 
ically expressed  is  melancholia  syphilophohica.  The  cause  lies  in 
fonner  or  present  peculiarities  that  may  be  quite  harmless.  How- 
ever, it  is  worthy  of  note  that  this  form  of  mental  disturbance  is  fre- 


PSYCHONEUROSES— PRIMARY  CURABT.E  R^I^ATKS.  305 

qucnt  in  those  that  are  infected  or  in  whom  infection  is  suspected. 
In  such  cases  luetic  chlorosis  or  anemia  due  to  a  course  of  mercury 
and  iodides  seems  etiologically  important. 

As  a  variety,  hydrophobic  melancholia  may  be  mentioned.  The 
patient  explains  his  disturbance  of  general  sensüjüity  and  apprehen- 
sive state  of  mind  by  the  delusion  of  having  been  infected  with 
rabies,  and  he  lives  in  the  fear- of  an  outbreak  of  this  terrible  disease 
and  of  communicating  it  to  others.  At  the  height  of  apprehensive 
excitement  there  may  be  reflex  cramps  and  inability  to  swallow.  A 
former  dog-bite  or  some  harmless  accident  may  be  the  cause  of  the 
development  of  this  delusion. 

II.  Melancholia  avith  Stupoe,  or  Melancholia  Attonita 
OR  Stupida. 

Melancholia  with  stupor  is  a  grave  clinical  form  of  melancholia 
characterized  by  profound  disturbance  of  consciousness,  complete  in- 
hibition of  mental  activity,  with  the  addition  of  peculiar  psycho- 
motor disturbances. 

In  this  disease  the  patients  are  quite  absorbed  in  themselves, 
without  will,  and  apparently  completely  separated  from  the  external 
world.  Superficially  they  are  like  dements,  and,  in  fact,  early  ob- 
servers, with  the  exception  of  Baillarger,  mistook  this  condition  for 
primary  dementia  and  states  of  stupor.  Baillarger  first  recognized 
the  melancholic  nature  of  this  malady  by  proving  that  in  the  disease- 
picture  there  were  melancholic  delusions,  and  by  showing  that  the 
apparent  lack  of  will  of  the  patients  was  but  an  intense  degree  of 
psychomotor  inhibition. 

Very  rarely  this  disease-picture  develops  primaril}^,  and  when  it 
does  it  seems  to  be  dependent  upon  an  especially  weakened  or  vul- 
nerable brain  (typhoid,  puerperium)  affected  by  a  sudden  and  in- 
tensely acting  exciting  cause  (emotional  shock,  fright,  etc.).  As  a 
rule,  however,  it  appears  secondarily,  and  is  gradually  developed  out 
of  a  simple  melancholia,  for  the  most  part  following  upon  a  stormy 
outbreak  of  apprehension  or  despair  or  some  act  of  violence. 

The  disturbance  of  consciousness  in  these  patients,  owing  to  the 
absence  of  the  possibility  of  reaction,  seems  much  more  profound 
than  it  actually  is.  An  attentive  observer  sees  in  the  wrinkling  of  the 
brow,  the  winking  of  the  eyes,  the  ap]orehensive  look,  an  intention 
to  draw  away  which,  of  course,  is  expressed  only  in  a  more  powerful 
contraction  of  muscles  in  the  patient  otherwise  immobile,  the  exist- 
ence of  apperception  of  the  external  world. 


306  SPEriAL  PATHOLOGY  AN  H    rilKHAPY  OF  INSANITY. 

Too,  the  fact  that  the  patients  have  at  least  a  suiiiniary  inciiiory 
for  the  events  of  tlie  disease,  sometimes  even  memory  of  minute 
details,  proves  that  tlieir  stupor  is  not  profound. 

Xatiuiillv,  vu\y  wlu-ii  tliese  patients  are  able  later  to  desnibe  their  feel- 
ings, ill  the  period  of  convalescence,  can  notions  of  the  inner  psychic  activities 
during  this  peculiar  painful  state  of  inhibition  be  obtained.  Quit©  in  contrast 
with  a  tabula  rasa,  these  patients  tell  uf  tlie  most  plastic  and  horrible  hal- 
lucinations and  delusions  to  which  they  were  subject:  of  frightful  pictures  of 
death-agony,  execution,  slaughter  of  dearest  relatives,  or  ilestruction  of  the 
world,  lu  severe  cases,  tiie  inner  life  of  such  patients  becomes  a  true  nebulotis 
state  of  consciousness,  in  \\iiich  objecti\e  external  impressions  seem  confused, 
shadowy,  and  hostile.  A  frightful,  vague,  empty  fear  which  paralyzes  all 
energy  takes  possession  of  consciousness  and  reason  and  makes  motor  reac- 
tion impossible;  and  the  frightful  consciotisness  of  powerlessness  to  act  and 
will  increases  the  distress  tenfold.  In  harmony  with  this  state  of  conscious- 
ness the  patients  are  fixed  like  a  statue  in  one  place,  with  anxiotis,  astonished, 
or  mask-like  fixity  of  feattires  devoid  of  reaction. 

The  attitude  is  bent,  the  muscles  are  strained  and  in  slight 
flexion  (tetany),  which,  when  the  passive  patient  is  taken  hold  of, 
increases  to  enormous  resistance  that  can  only  be  overcome  Ijy  the 
use  of  great  force. 

In  rare  cases  the  muscles  do  not  show  this  rigidity  and  flexed 
attitude  of  the  members.  They  offer  no  resistance  to  passive 
movements,  but  remain  a  long  time  in  the  position  given  them 
(cataleptiform  state),  without  presenting,  however,  the  phenome- 
non of  flexibilitas  cerea.  In  a  very  few  cases,  however,  this  does  occur 
(catalepsy). 

As  a  part  of  the  general  psychomotor  inhibition  mutism  occurs. 

Concerning  the  state  of  sensibility  of  these  patients,  a  conclusion 
is  difficult,  since  they  cannot  speak  and  are  otherwise  inhibited  in 
their  reaction.  However,  for  the  most  part  sensibility  is  retained, 
and  only  the  expression  of  pain  is  interfered  with.  In  a  few  cases 
there  was  temporary  hyperesthesia;  in  a  few  others,  and  especially 
severe  cases,  there  was  central  anesthesia.  The  heart's  action  is 
usually  increased,  the  pulse  small  and  rapid,  and  the  artery  wire-like. 
Turgor  vitalis  is  wanting,  the  skin  is  dry  and  rough,  and  the  patients 
look  much  older  than  they  are.  Eesjnration  is  slow,  superficial,  and 
thus  insufficient;   body-temperature  is  subnormal. 

The  secretions  are  lessened  and  the  menses  wanting.  The  gen- 
eral nutrition  falls  decidedly.  There  is  passive  resistance  to  taking 
food,  which  not  infreciuently  makes  it  necessary  to  resort  to  forced 
feeding.  Constipation  is  almost  constant  and  often  very  obstinate. 
In  severe  cases  with  an  unfavorable  course  Dagonet  also  observec] 


PSYCHONEUROSES— ^HI^^AHY  düARLl!:  S'I'ATES.  007 

salivation.  If  the  malady  take  an  unfavorable  course,  then  gradually 
the  fixity  of  the  features  and  the  limbs  diminishes,  and.  there  is  relax- 
ation, with  only  partial  contractures  to  betray  the  former  state.  The 
patient  dements,  becomes  constantly  unclean,  and  the  general  phys- 
ical condition  improves.  The  pulse  becomes  slow,  and  there  is  cool- 
ness, cyanosis,  and  edema  of  the  extremities. 

The  course  is  remittent  with  exacerbations.  Periods  of  diminu- 
tion of  the  inhibition,  in  which  the  patient  goes  about  weeping  and 
can  communicate  in  words  spoken  with  a  low,  uncertain,  trembling 
voice,  and  in  which  there  is  also  a  certain  amount  of  spontaneity,  as  in 
eating,  alternate  with  periods  of  complete  immobility  and  stuporous 
inhibition.  Suddenly  out  of  such  a  state  of  inhibition,  in  such  pa- 
tients, raptus-like  acts  of  self-injury  or  violence  toward  others  may 
arise.  These  usually  occur  when  the  patient  has  been  disturbed  in 
his  painful  passivity  by  efforts  of  attendants  or  by  the  administra- 
tion of  food. 

The  anatomic  findings  are  anemia,  venous  stasis,  and  edema  of  tlie  pia 
and  brain.  In  protracted  eases  that  have  passed  on  to  dementia  there  is  also 
cortical  atrophy.  These  changes,  first  appearing  as  anemia  and  later  as  de- 
generation of  the  psychic  organ,  depend  upon  profound  disturbances  of  cere- 
bral nutrition,  primarily  due  to  vascular  paralysis,  weakened  heart's  action, 
and  hydremia. 

Case  10. — Melancholia  with  stupor;  tetany. 

G.,  aged  22,  lay  brother  in  a  cloister,  of  healthy  family,  fell  sick  in  the 
middle  of  October,  1875,  with  melancholia  and  Avas  brought  to  the  clinic  No- 
vember 14,  1875.  The  patient  had  never  been  sick  before.  Owing  to  his 
preference  for  such  a  life,  a  short  time  before  he  had  entered  a  cloister,  but 
there  had  quickly  found  that  he  had  deceived  himself.  In  the  middle  of  Octo- 
ber he  made  himself  remarked  by  his  silence,  his  constant  staring  befoi-e  him, 
and  his  unwillingness  to  work  and  eat.  Since  he  was  silent  and  apprehensive 
and  refused  food,  he  was  brought  to  Gratz.  On  admission  the  patient  was 
profoundly  anemic  and  much  reduced  in  general  strength.  He  was  of  medium 
height,  thin,  and  the  cranium  somewhat  prominent  at  the  sides,  slightly 
rachitic;  pupils  dilated,  reacting  slowly;  pulse  ve^-y  slow  and  the  radial  ar- 
tery contracted;  extensive  intercostal  neuralgia.  Constipation.  Conscious- 
ness is  profoundly  disturbed  and  dreamy.  The  facial  expression  is  painful  and 
fixed.  The  patient  lies  curled  up  in  bed  in  a  state  of  general  tetanic  con- 
tracture, the  eyes  tightly  closed.  He  does  not  speak  at  all,  except  to  say 
occasionally  that  he  is  forbidden  to  speak.  Now  and  then  he  sighs.  Respira- 
tion is  superficial;  skin  dry,  cool,  and  slightly. cyanotic;  patient  ofi"ers  great 
passive  resistance.  It  is  necessary  to  resort  to  forced  feeding.  The  treatment 
consists  first  of  rest  in  bed,  iron,  rubbing,  wine,  and  nutritioiis  food. 

An  attempt  to  overcome  the  contraction  of  the  arteries  with  amyl  nitrite 
has  little  success.  The  vascular  spasm  does  not  diminish,  and  the  pulse  from 
54  rises  only  temporarily  to  70.    The  patient  remains  in  a  state  of  profound 


30S  SPEriAT.  PArilOLOOY  AND  TIIEUAPY  OF  JXSAXITV. 

distiirbaiue  of  consciousness  and  tetany.  Only  the  painful  expression  and 
occasional  sighs  indicate  the  painful  state  of  consciousness.  Now  and  then 
the  patient  becomes  apprehensive,  restless,  crawls  under  the  bed  or  kneels  near 
it,  asking  to  be  forgiven.  Patient  sleeps  little,  loses  weight,  and  there  is  even 
decubitus  over  the  sacrum,  ^\■hile  during  the  daytime  the  patient  was  stupid 
and  passive  and  refvised  olTcred  food,  in  the  course  of  January,  1S7G,  during 
the  night  he  got  out  of  beti,  wandered  about  seeking  food,  and  greedily  ate  that 
which  purposely  had  been  left  where  he  could  obtain  it. 

In  the  beginning  of  Marcli,  1S7U,  Avith  improvenienL  in  general  condition, 
tlie  patient  became  freer  in  mind  and  movement.  He  was  still  shy  of  others, 
still  profoundly  depressed,  and  begged  often  for  forgiveness. 

In  April  these  melancholic  symptoms  diminished.  The  pulse  became 
softer,  fuller,  and  more  rapid.  Pie  opened  his  eyes,  began  to  speak  and  to 
occupy  himself;  he  became  clean  and  washed  and  dressed  himself.  He  was 
still  for  a  long  time  remarkably  inhibited  in  movement,  and  stared  before  him 
dreamily.  In  May  it  was  possible  to  examine  him.  The  patient  knew  only 
that  he  had  been  a])prphensive,  sleepless,  confused  in  his  head,  and  feared  to  be 
killed  on  account  of  great  sins.  The  period  from  his  admission  up  to  the  end 
of  iMarch,  1876,  he  could  recall  but  imperfectly,  knowing  only  that  he  was  very 
apprehensive  and  could  not  move.  It  seemed  to  him  that  he  had  slept  during 
all  this  time.  Convalescence  progres.sed  undistiu'bed,  and  at  the  end  of  Sep- 
tember, 1876,  the  patient  was  discharged  recovered. 

The  Coukse  axd  Termin' atioxs  of  jMelaxciiolia. 

Tlie  inclancliolic  state  occurring  at  the  beginning  of  the  various  neuroses 
and  i^sychoses  as  an  intercurrent  disturbance  in  the  initial  stages  of  a  disease 
must  be  carefully  differentiated  from  melancholia  as  a  form  of  disease. 

There  is  very  frequently  a  melancholic  symptom-complex  as  a  prodromal 
manifestation  in  mania  and  as  an  intercurrent  phenomenon  in  senile  dementia 
and  dementia  paralj'tica;  also  in  epileptics,  hysterics,  hypochondriacs,  neuras- 
thenics, and  sometimes  in  paranoiacs.  It  is  only  melancholia  as  a  form  of 
disease  that  can  be  the  object  of  special  clinical  discussion. 

The  course  of  melancliolia'  in  continuous,  and  subacute  or 
clironic.  Where  its  course  is  subacute,  the  disease-picture  quickly 
reaches  its  height,  and  precordial  distress,  delusions,  and  errors  of 
the  senses  are  earl}^  developed.  The  disease-picture  may  for  weeks 
or  months  manifest  itself  in  the  form  of  melancholia  without  de- 
lusion; the  subsequent  occurrence  of  precordial  distress  forms  then 
another  phase;  until  finally  delusions,  and  frequently  also  errors  of 
the  senses,  bring  the  disease  to  its  full  development.  At  this  point 
the  disease  usually  remains  for  months. 

Melancholic  insanity  in  all  its  stages  shows  remissions  and  ex- 
acerbations. These  are  partly  due  to  organic  and  partly  to  psycho- 
logic processes,  Eemissions,  if  there  be  any,  almost  always  occur  in 
the  afternoon  and  evening,  and  exacerbations  occur  in  the  earlier 


PSYCHONKUÜOSKS-l'UIMARY  ClIüAlil.E  8TATKS.  309 

hours  of  the  morning.  The  reason  for  this  is  largely  (luo  to  the  fact 
that  precordial  distress  usiuilly  dJuiinislies  in  ijitensity  durjug  the 
course  of  the  day. 

The  disappearance  of  the  disease  is  gradual,  not  sudden — at 
least  in  chronic  and  essentially  melancholic  insanity.  Kemissions 
become  more  pronounced  and  enduring;  sleep  and  nutrition  improve. 
The  patient  begins  to  doubt  the  reality  of  his  delusions  and  hallucina- 
tions, and  the  latter  gradually  disappear. 

In  rare  cases  of  melancholia  with  stupor  a  disappearance  of  the 
disease  in  a  few  days  has  been  observed,  with  manifestations  which 
indicated  restoration  of  normal  circulation  and  probable  reabsorption 
of  edema.    The  duration  of  true  melancholia  is  months  or  years. 

When  the  innumerable  slight  cases  that  do  not  reach  the  hos- 
pital for  the  insane  are  taken  into  consideration,  the  prognosis  of 
melancholia  is  favorable.  Numerous  cases  of  this  kind  remain  at 
the  degree  of  melancliolia  without  delusion,  or  have  in  addition  only 
precordial  distress,  and  pass  on  to  recovery  without  the  occurrence 
of  delusions  or  errors  of  the  senses. 

States  of  simple  melancholia  in  transition  to  melancholia  with 
stupor  have  a  graver  prognosis.  This  state  of  profound  psychic  inhi- 
bition easily  passes  on  to  actual  mental  weakness.  This  is  still  more 
to  be  feared  in  actual  melancholia  with  stupor,  which  prognostically 
is  to  be  regarded  as  the  severest  form;  but  in  youthful  patients,  and 
with  early  and  proper  treatment,  the  results  are  frequently  favorable. 

In  general,  the  forms  of  ac'tive  melancholia  that  have  a  more 
subacute  course  allow  a  more  favorable  prognosis  than  cases  of  pas- 
sive melancholia,  though  in  the  former  cases,  especially  in  elderly 
individuals,  there  is  danger  of  exhaustion  and  inanition.  Aside  from 
termination  in  recovery,  which  takes  place  in  about  60  per  cent,  of 
cases  treated  in  insane  hospitals,  and  aside  from  a  fatal  result,  some- 
times due  to  exhaustion,  to  colliquative  diarrhea  dependent  upon 
venous  stasis  in  the  intestinal  mucous  membrane,  to  pulmonary 
tuberculosis  caused  by  the  profound  disturbance  of  nutrition,  and 
also  in  rare  cases  to  progressive  cerebral  paralysis,  termination  in  a 
state  of  mental  weakness  is  to  be  mentioned.  The  terminal  stage  of 
melancholia  that  has  not  gone  on  to  recovery  may  be  either  sec- 
ondary delusional  insanity  or  dementia.  The  last  result  is  not  in- 
frequently the  direct  termination  of  melancholia  with  stupor,  while 
in  unfavorable  cases  of  simple  melancholia  secondary  delusional  in- 
sanity is  more  frequently  observed. 


310  SPD  TAT.   I'ATIIOLOCY  AXD  TTTKRAPY  OF  IKSAXTTY. 

Therapy. 

Tlie  following  gonoral  principlcs  for  the  trcntnuMit  of  melan- 
cholia may  be  laid  down: — 

1.  Give  the  patient  conii)lete  physical  and  mental  rest,  liemove 
all  sources  of  iro-itation  of  the  diseased  brain,  whether  these  be  efforts 
to  distract  or  enconrage  the  patient,  religious  consolation,  etc.,  re- 
membering always  that  impressions  that  under  normal  condilions 
make  pleasant  impressions  can  only  increase  the  mental  pain. 

This  indication  becomes  more  important,  the  greater  the  psychic 
hyperesthesia  and  the  more  acute  the  case.  For  the  majority  of 
inelancholics  rest  in  bed  is  the  most  iin})ortant  medical  prescription 
and  does  the  greatest  amount  of  good.  For  melancholies  with  cere- 
bral anemia,  especially,  there  is  no  better  means  to  quiet  them. 

2.  Surveillance  of  the  patient  to  protect  him  from  himself  and 
■  others  from  him.     Every  melancholic  is  capable  of  suddenly  making 

an  attempt  against  his  own  life,  and  every  one  is  also  dangerous  to 
others.  The  watching  of  the  patient  must  be  continuous.  The 
slyness  and  persistence  of  such  patients  in  pursuit  of  their  suicidal 
intentions  is  often  astounding.  Eestraint  by  means  of  a  camisole  is 
no  guarantee  against  suicide. 

3.  Care  of  the  general  condition  and  of  the  amount  of  food 
taken. 

Sleeplessness,  affects,  and  irregular  eating  with  disturbed  as- 
similation due  to  catarrhal  affection  of  the  alimentary  tract  predis- 
pose to  inanition,  exhaustion,  and  to  tuberculosis  when  there  is  a 
predisposition  to  it.  Therefore  such  patients  must  be  given  abundant 
food,  easily  digestible  and  rich  in  proteids. 

This  indication  can  frequently  be  fulfilled  only  with  great  difficulty  on 
account  of  the  tendency  of  the  patient  to  refuse  food.  In  order  to  oppose 
this  rationally,  it  is  necessary  to  discover  its  cause.  The  causes  of  refusal  of 
food  are  vai'ious. 

Sometimes  it  is  simply  catarrh  of  the  mouth,  stomach,  or  intestines,  and 
proper  treatment  overcomes  the  difficulty.  l''refiuently  the  cause  is  consti- 
pation, and  proper  treatment  quickly  attains  tlie  desiied  result.  More  fre- 
q\iently  the  cause  is  mental.  In  many  cases,  especially  where  the  patients  are 
naturally  of  limited  mental  endowment,  the  refusal  of  food  is  simply  due  to 
the  i7upulse  of  opposition  caused  by  the  painful  and  hostile  conception  of  the 
external  world.  If  this  state  of  mental  opposition  be  ij^nored,  as  a  rule  resist- 
ance is  overcome,  or  the  patient  can  be  sufficiently  nourished  by  leaving  food 
accidentally  near  him,  as  if  it  wei-e  unintentional,  and  thus  it  is  possible  for 
him  to  eat  unnoticed. 

In  melancholia  attnnita  the  refusal  of  food  is  due  to  disturbance  of  ap- 
perception   and    general    psychomotor    inhibition.     lu    such    a    coiiditiou    the 


PSYCHONETTRORES— PRIMARY  f'lJüAßLE  STATES.  ',]-[\ 

patient  would  simply  starve  to  death,  because  his  bodily  needs  are  not  per- 
ceived, necessary  ideas  are  not  formed,  and  it  is  impossible  for  him  to  act. 
Under  such  circumstances  not  infrequently  energetic  scolding  induces  the 
patient  to  eat.  If  active  interference  be  necessary,  the  resistance  is  usually 
easily  overcome  with  a  spoon  or  an  invalid  feeding-cup. 

In  certain  melancholies  who  refuse  food,  refusal  is  due  to  religious 
motives,  to  delusions  of  sin  or  of  need  to  do  penance,  etc.  Not  infrequently 
as  a  cause  is  the  profound  feeling'  of  unworthiness,  of  no  longer  being  worthy 
of  food,  and  of  taking  it  from  the  poor  and  more  worthy;  or  there  is  a 
nihilistic  delusion  that  nothing  longer  exists,  that  everything  has  been  de- 
stroyed, or  that  the  patient  can  no  longer  pay  for  anything. 

In  other  cases,  errors  of  the  senses  of  taste  and  smell,  and  a  consequent 
delusion  of  poison,  of  uncleanliness  of  the  food,  cause  refusal  of  nourishment. 
In  hypochondriac  melancholia  the  cause  of  the  refusal  of  food  may  lie  in  dis- 
turbed general  sensibility  and  consequent  delusions  that  the  alimentary  tract 
is  obstructed,  the  body  dead,  the  organs  decayed,  or  the  stomach  gone.  Some- 
times the  patient  obeys  voices  which  command  him  to  refuse  food,  and  less 
freqiiently  the  patient  tries  to  kill  himself  by  starvation.  When  delusions, 
hallucinations,  or  disgvist  with  life  are  influential,  it  is  frequently  necessary  to 
feed  the  patient  by  force. 

4.  Treatment,  by  proper  means,  of  sleeplessness,  which  is  very 
exhausting  and  favors  the  development  of  delusions  and  hallucina- 
tions. Morphine  is  of  little  service;  chloral  hydrate  is  more  valua- 
ble, though  it  cannot  be  used  freely  for  a  long  time.  Opium  is  better, 
as  are  also  sulphonal  and  trional.  Assistance  is  given  by  lukewarm 
baths,  especially  when  prolonged;  mustard-baths  and  Preissnitz 
packs.  In  anemic  patients,  alcoholic  stimulants,  especially  strong 
beer,  have  a  good  effect,  and  in  such  cases  it  is  Avell  to  have  the  prin- 
cipal meal  taken  in  the  evening. 

5.  Use  of  symptomatic  remedies  approved  by  experience.  The 
first  of  these  are  lukewarm  baths  of  from  26°  to  28°  R.  (90°  to  95° 
F.),  continued  several  hours,  according  to  circumstances,  and  opium 
(comp,  page  258).  Opium  is  especially  indicated  in  precordial  and 
agitated  melancholia ;  in  cases  due  to  anemia  and  alcoholism,  and  in 
the  early  stages  of  the  disease  and  in  females.  The  dose  to  begin 
with  shou^ld  be  0.03  gram  twice  daily,  increased  rapidly  by  0.01  gram 
at  each  dose  (comp,  page  259).  The  favorable  effect  of  the  remedy 
when  it  is  indicated  is  soon  shown,  first  in  hope  and  quiet.  There  is 
seldom  indication  of  toxic  effect,  and  the  first  constipating  influence 
soon  passes  off.  The  subcutaneous  administration  of  the  aqueous 
extract  of  opium  i;»  the  best  on  account  of  sparing  the  stomach  and 
the  certainty  of  the  dose. 

Congestive  symptoms  do  not  in  themselves  contra-indicate  the 
remedy.     The  maximum  dose  cannot  be  stated.     If  for  any  reason 


312  SPECTAL  TATIIOLOnY  AND  TIIEIJAPY  OF  IXSANTTY. 

the  subcutaneous  administration  is  not  possible,  then  the  aqueous 
extract  of  opium  may  be  given  internally  with  sherry.^ 

The  minute  fulfillment  of  all  hygienic  demands  is  especially 
necessary  in  severe  cases  of  passive  melancholia  and  inohiiicliolia  with 
stupor.  Such  patients  must  be  kept  constantly  in  bed,  by  which 
means  stasis  of  the  blood  and  unnecessary  loss  of  heat  are  prevented. 

The  diet  should  be  rich  in  proteids,  but,  owing  to  the  condition 
of  the  digestive  tract,  mild.  For  this  purpose  milk  and  its  prepara- 
tions are  most  suitable.  Daily  care  of  the  bowels  is  not  less  im- 
portant, but  drastics  must  be  avoided.  The  insufficient  respiration 
may  reciuire  sina]iisms  and  faradization  of  the  muscles  of  the  chest 
and  of  the  diaphragm.  If  the  heart's  action  is  deficient,  diffusible 
stimulants  may  be  required,  especially  good  old  wine,  and  under  some 
circumstances  ether  and  camphor.  If  at  the  same  time  the  pulse  is 
spasmodically  contracted,  then  am}^  nitrite,  or  plenty  of  hot  grog, 
hot  brandy,  and  the  like,  may  be  useful.  These  remedies  promote 
sleep  better  than  any  narcotic.  The  reduced  activity  of  the  skin  may 
require  stimulation  by  mustard-baths  and  washings  with  warm  vine- 
gar. Opium  is  of  no  service  in  these  conditions;  on  the  contrary, 
it  is  rather  harmful. 


CHAPTER  II. 

Mania. 


The  fundamental  symptoms  of  maniacal  insanity  are  a  change 
of  self-consciousness  characterized  by  a  predominating  pleasurable 
emotional  state,  and  an  abnormal  ease  and  rapidity  of  thought  which 
may  become  so  intense  that  all  control  of  the  psychomotor  side  of  the 
mind  is  wanting.  In  this  respect  mania  is  the  exact  opposite  of  mel- 
ancholia. In  mania,  no  more  than  in  melancholia,  can  the  emotional 
anomalies  be  exclusively  explained  by  the  changed  activity  of  mental 
processes  (here  facilitated),  though  it  cannot  be  denied  that  a  decided 
increase  of  pleasurable  feeling  is  found  by  the  patient  in  the  greater 
ease  of  thought  and  the  removal  of  all  inliil)itinn.- 

^  IJ  Aq.  ext.  thebaic, 0.6 

■\'in  malaceus, HO.O 

Aquae    dest.,  'if^O 

Syr.   aurant.   cort., 1-3.0 

M.  Sig. :  Dessertspoonful  at  a  dose.  (Dessei-tspoonful  equals  about 
0.02  gram  of  thebaic.) 

-  Mendel  declares  the  emotional  anomaly  to  be  a  subsidiary,  secondary 
symptom  dependent  upon  the  content  of  thought,  the  greater  ease,  and  the 


PSYCHONEÜROSE.S— PETMARY  f:URABLE  STATE.S.  313 

Both  these  furidamental  phenoincna  are  to  be  regarded  as  co- 
ordinated, and  probably  their  foundation  lies  functionally  in  facili- 
tated expenditure  of  vital  forces,  and  anatomically  in  a  greater  supply 
of  blood  to  the  psychic  organ.  In  mania,  also,  two  essential  disease- 
pictures  may  be  distinguished,  differing  only  in  degree  and  frequently 
passing  one  into  the  other.  The  milder  form  is  maniacal  exaltation; 
the  severer  form  is  furious  mania. 

I.  Maniacal  Exaltation-.^ 

Psychic  Symptoms. — The  content  of  consciousness  is  pleasure 
and  psychic  well-being.  It  is  just  as  independent  of  events  in  the 
external  world  as  the  opposite  state  of  mental  pain  in  melancholies, 
and  therefore  can  be  referred  only  to  inner  organic  causes.  The 
patient  revels  in  pleasurable  feelings,  and  after  recovery  states  that 
never  in  health  did  he  feel  so  uplifted  or  so  happy  as  during  his 
disease.  This  sjiontaneous  pleasure  receives  powerful  stimulation 
from  altered  apjoerception  of  the  external  world;  from  the  realization 
of  the  facilitated  activity  of  thought  and  will;  from  the  intense  ac- 
centuation of  ideas  with  pleasurable  feelings;  and  the  comfortable 
state  of  general  feeling,  especially  that  derived  from  the  muscles 
(increased  mAiscle-tone).  These  influences  cause  the  joyful  emotion 
to  be  intensified  temporarily  to  joyful  atfects  (unrestrained  joyous- 
ness,  wantonness),  which  find  their  expression  in  singing,  dancing, 
jumping,  and  silly  jokes. 

Along  with  the  disturbance  in  content  of  emotion  there  is  a 
formal  derangement — increased  excitability  (psychic  hj'peresthesia), 
manifest  in  the  fact  that  sense-perception  and  reproduced  ideas  are 
accompanied,  not  by  mere  sentiment,  but  by  affects  which,  owing  to 
the  predominating  fundamental  emotional  state,  are  principally  gay; 
and  they  occur  with  abnormal  ease.    Necessarily  on  account  of  this 


greater  or  lesser  obstacles  which  the  impulse  to  movement  experiences.  He 
defines  mania  therefore  as  a  "functional  brain  disease  characterized  by  ab- 
normal rapidity  of  thought,  and  by  abnormally  increased  excitability  of  the 
cerebral  motor  centers."  In  opposition  to  this,  it  should  be  pointed  out  that 
there  are  periods  when  the  maniacal  patient  is  amenomaniacal,  without  pre- 
senting the  impulse  to  think  or  the  rapid  flight  of  ideas,  and  that  the  intensifi- 
cation of  the  rapidity  of  thought  is  in  no  way  in  relation  to  the  degree  of 
the  pleasurable  emotional  state.  Moreover,  rapid  flight  of  ideas  occurs  in 
delirious  fever  patients,  etc.,  without  pleasurable  emotion;  and,  on  the  other 
hand,  alcohol  may  induce  such  a  state  of  feeling  without  simultaneously  in- 
creasing the  rapidity  of  thought. 

"^  Synonyms:    Hypomania — Mendel;    furious  mania — Schule. 


;1U  SPEnTA4.  PATHOl.OCY  AND  TIIKIIAPY  OV  INSANITY. 

there  is  an  altered  apperception  of  the  external  world.  Instead  of 
the  somber  color  with  which  the  external  world  appears  to  the  melan- 
cholic as  a  result  of  his  psychic  dysesthesia,  to  the  maniacal  it  seems 
warmer,  more  beautiful  and  interesting.  On  this  account  he  culti- 
vates associations,  goes  into  society,  travels,  in  contrast  again  with 
the  melancholic,  who  avoids  people  or  even  detests  them. 

The  general  result  of  the  changed  process  of  apperception  of  the 
external  world  and  of  self  is  an  increased  estimate  of  self -value  which 
frequently  finds  its  expression  in  personal  adornment. 

Though  a  joyful  emotion  forms  the  emotional  basis  of  maniacal 
insanity,  contrary  feelings  are  not  therefore  excluded.  Owing  to  the 
xmlimited  association  of  ideas  and  their  lively  coloring,  opposing  ideas 
may  be  called  up.  Frequently,  however,  they  arise  artificially  from 
restraint  of  the  freedom  of  the  patient,  from  opposition  to  his  wishes, 
etc.,  by  which  the  abnormally  intensified  feeling  of  self-valuation  is 
hurt.  These  painful  and  choleric  states  of  feeling,  however,  are  only 
episodic,  and,  owing  to  the  increased  rapidity  of  thought,  are  quickly 
overcome  by  the  pleasurable  fundamental  emotion.  In  thought  the 
rapidity  of  the  transformation  of  psychic  energy  is  expressed  in 
facilitated  reproduction,  association,  and  combination  of  ideas,  which 
necessarily  lead  to  an  overfilling  of  consciousness;  they  thus  stand  in 
striking  contrast  with  the  monotony  and  inhibition  of  the  activity  of 
thought  observed  in  melancholia. 

With  the  facilitation  of  reproduction  and  apperception  and  the 
warm  coloring  of  thought  and  apperception,  the  patient  becomes 
more  plastic  in  his  diction  and  remarks  at  once  the  point  of  the  sub- 
ject, the  weaknesses  and  peculiarities  of  those  about  him;  he  is 
quicker  in  his  comprehension,  and,  owing  to  his  facilitated  association, 
is  at  the  same  time  ready,  witty,  and  humorous,  even  to  irony.  The 
overfilling  of  consciousness  gives  him  an  inexhaustible  supply  of  sub- 
jects of  conversation,  and  the  greatly  increased  rapidity  of  thought, 
in  which  long  connecting  links  are  manifest  only  by  slight  indications 
without  being  verbally  expressed,  makes  his  train  of  thought  appear 
interrupted. 

The  intensified  valuation  of  self  causes  natural  language  to  be 
disdained,  and  the  patient  tries  to  express  himself  in  literary  lan- 
guage. During  the  stage  of  maniacal  exaltation  of  maniacal  insanity 
there  may  be  disturbances  in  the  content  of  thought  that  are,  for 
the  most  part,  episodic,  and  consist  of  rendering  allegoricaliy  ob- 
jective the  intensified  feeling  of  self-aggrandizement.  Occasionally 
the  patient  compares  himself  with  a  distinguished  personality  with- 
out identifving  himself  with  the  individual. 


fSYCHONErnnsKS— iTJMAüV  r'T'i?AT;LK  ST-ATKS.  ,mr< 

His  conscioiisnGRS  is  too  littlo  disinrhcd  to  prTinii  tliis.  ITe  is 
always  able  to  exercise  critical  jiulgnient  of  his  own  condition,  and 
describes  his  state  of  mind  as  abnornial,  in  that  he  excuses  his  hasty 
actions,  for  want  of  a  better  explanation,  1)y  saying  that  he  is  a  Tool 
and  that  to  sncli  an  individual  everytJiing  is  permitted. 

There  may  be  hallucinations,  but  at  most  they  are  only  tempo- 
rary, and  are  usually  corrected;  or  at  least  they  are  never  acted  upon. 
Illusions  occur  more  readily,  owing  to  the  greatly  increased  activity 
of  thought. 

On  the  psychomotor  side  of  mental  activity  the  disturbance  is 
first  manifest  in  increased  will  and  impulse;  but  all  motor  acts  of 
the  patient,  in  contrast  with  furious  mania,  are  of  psychic  origin  and 
take  place  consciously. 

Their  causes  are  affective  states  or  clearly  conscious  ideas.  They 
are  like  normal  acts,  only  remarkable  in  that  they  are  hurried,  ill 
considered,  irrelevant,  jocular,  shocking,  or  even  immoral,  without, 
however,  presenting  the  possibility  of  characterizing  them  as  abso- 
lutely unreasonable  {comp,  page  95).  This  exaltation  of  the  psy- 
chomotor side  of  niental  activity  is  clinically  expressed  in  desire  to 
wander,  frequent  saloons,  seek  out  old  friends  and  acquaintances,  see 
notable  places,  write,  make  purchases,  etc.  The  absence  or  too  late 
occurrence  of  inhibitory  controlling  ideas  causes  these  acts,  which  in 
themselves  are  not  senseless,  but  only  irrelevant  and  hasty;  and 
since,  at  the  same  time,  there  is  an  absence  of  esthetic  and  ethic 
inhibitory  ideas,  they  are  frequently  shocking.  The  lively  coloring 
of  all  perceptions  by  pleasurable  emotion  causes  such  patients  to  be 
full  of  desire;  and  their  abnormally  intensified  feeling  of  self- 
aggrandizement  renders  them  troublesome,  talkative,  and  disputative. 
The  transitoriness  of  their  impulses  causes  them  to  be  inconsistent, 
incapable  of  all  occupation,  and  unable  to  complete  whatever  they 
have  undertaken. 

ISTot  in  all  of  these  patients  are  the  general  features  of  the 
disease  developed.  In  some  cases  the  impulse  to  talk,  in  others  in- 
tensified volition,^  and  in  still  others  pleasant  emotion  is  the  most 
prominent  symptom;  and  in  the  latter  case  it  may  be  either  a  simple 
exaltation  or  have  an  erotic  or  religious  coloring. 


^  Under  such  circumstances,  not  infrequently  there  is  an  impulse,  impor- 
tant from  a  legal  standpoint,  to  collect  and  steal  objects,  sometimes  due  to  un- 
controlled desire  (directed  to  food,  alcohol,  jewels,  or  even  to  money  as  a 
means  to  an  end)  ;  sometimes  caused  by  a  desire  to  joke,  or  injure  and 
embarrass  others;    or  as  a  result  of  illiLsions  and  the  impulse  to  activity. 


31(j  Sl'F.eiAL   I'ATllOLOdY   AND  TIIKK Al'V   OF   INSANITV. 

It  is  not  worth  while  to  give  names  to  these  various,  clinical  va- 
rieties. Ahnost  always — and  in  females,  indeed,  always — in  maniacal 
exaltation  the  sexual  sphere  occupies  the  foreground  of  conscious- 
ness. The  sexual  impulse  expresses  itself  here  in  a  superficial  dis- 
turbance-that  is  still  tolerable:  in  men,  by  paying  attentions  to 
women,  hasty  promises  of  marriage,  questionable  allusions  in  conver- 
sation, visits  to  brothels ;  in  ^vomen,  in  inclination  to  self -adornment, 
to  seek  male  society,  to  flirt,  to  talk  of  scandal,  to  invent  stories  of 
love-intrigues,  and  in  suspicion  of  other  women  {comp,  page  82). 

Very  frequently  in  this  state  of  exaltation  there  is  an  increased 
desire  for  stimulants,  satisfied  in  highly  seasoned  food,  smoking,  tak- 
ing snuir,  drinking  strong  cofi:'ee,  and  especially  in  the  use  of  alcoholic 
drinks.  Under  such  circumstances  such  excesses  readily  lead  to  in- 
tensification of  maniacal  exaltation  to  the  height  of  furious  mania. 

Physical  Symptoms. — Disturbance  of  sleep  is  here  quite  con- 
stant. The  patients  sleep  but  a  few  hours,  get  up  in  the  middle  of 
the  night,  and  busy  themselves  about  the  hoiise  or  in  the  street. 
There  is  a  feeling  of  increased  physical  well-being,  of  increased  power 
and  capability  of  action.  The  patient  cannot  find  words  enough  to 
describe  his  maniacal  well-being,  his  infinite  good  health.  There  is 
here  no  feeling  of  physical  fatigue,  not  even  after  forced  walking  and 
other  kinds  of  over-exertion. 

But  the  patient  is  actually  fresher.  He  looks  younger,  his  turgor 
vitalis  is  increased,  his  expression  is  livelier,  his  vegetative  functions 
act  more  promptly;  the  appetite  is  increased,  but,  on  account  of  his 
great  motor  unrest,  he  often  finds  no  time  to  satisfy  it. 

In  spite  of  all  signs  of  increased  metabolism,  and  in  spite  of 
good  assimilation,  the  body-weight  falls.  The  muscle-tone  is  espe- 
cially increased.  The  muscles  are  firmer  and  more  turgescent.  The 
attitude  is  more  erect,  and  the  sureness  and  rapidity  of  movement  are 
greater  than  under  normal  circumstances.  Movements  take  place 
with  remarkable  promptness,  and  give  the  impression  that  the  will 
excites  more  immediately  the  motor  centers.  The  patient  himself 
becomes  conscious  of  this  facilitated  innervation  and  co-ordination, 
and  is  thus  further  incited  to  good  feeling  and  pleasure  in  activity. 

OccuEREXCE  AND  CouRSE. — Maniacal  exaltation  as  a  form  of 
disease  characterizing  the  whole  duration  of  a  case  of  mental  disturb- 
ance is  infrequent.  It  occurs  offener  as  an  episodic  manifestation. 
In  this  sense  it  is  a  prodromal  stage  or  a  remission  in  furious  mania, 
or  a  transitional  state  in  other  forms  of  insanity.  It  may  be  also  a 
phase  of  circular  or  hysteric  insanity.  As  a  prodromal  state  it  occurs 
in  general  paralysis  of  the  insane;   but  in  such  cases  it  is  peculiarly 


rSYCHONEUROSES— rill  MA RY  CIJÜABLIO  .S'J^A'l'ES.  '.]  \  7 

colored  by  signs  of  mental  weakness  wliioh  early  lend  a  iingc  to  its 
symptoms. 

As  an  independent  disease-picture  it  ap|)(;;irs  most  fre(|iient]y  in 
the  form  of  periodic  attacks  {vide  "Periodic  Maniacal  Insanity"); 
but  in  such  cases,  in  harmony  with  the  degenerate  foundation,  it 
takes  on  a  reasoning  and  irritable  color.  In  the  rare  cases  in  which 
maniacal  exaltation  is  independent,  and  not  a  part  of  a  periodic  psy- 
chosis, it  is  usually  preceded  by  a  melancholic  prodromal  stage.  Its 
course  is  remittent  with  exacerbations,  and  it  continues  weeks  or 
months.  It  may  fade;  its  disappearance  is  then  gradual,  not  sud- 
den, and,  in  accord  with  the  mildness  of  the  disturbance,  there 
is  a  stage  of  exhaustion  slightly  marked  and  of  short  duration  which 
follows.  In  other  cases,  especially  due  to  sexual  and  alcoholic  ex- 
cesses, it  passes  on  to  furious  mania.  The  prognosis  of  this  mildest 
form  of  maniacal  insanity  is  favorable,  and  without  the  danger  of 
psychic  defect  that  follows  furious  mania. 

Theeapy. — The  most  important  means  of  treatment  is  isola- 
tion adapted  to  the  degree  of  the  exaltation,  and  the  prevention  of 
all  abnormal  irritation,  especially  excesses.  For  many  cases  hospital 
treatment  is  sufficient,  where  an  isolated  room  may  be  temporarily 
necessarjr.  To  overcome  sleeplessness  and  restlessness  at  night, 
chloral  hydrate,  sulphonal,  and  trional  are  useful.  ISTarcotics,  espe- 
cially opium  and  morphine,  so  frequently  useful  in  periodic  cases,  are 
here  disadvantageous,  and  often  have  the  effect  to  increase  the  ex- 
citement. 

On  the  other  hand,  it  is  rare  for  lukewarm  baths,  especially  Avhen 
prolonged,  to  fail  to  produce  a  quieting  eifect  on  the  central  nervous 
system;  but  this  effect  lasts  usually  only  a  few  hours. 

Where  states  of  excitation  have  their  origin  in  the  sexual  system, 
it  is  well  to  administer  bromides.  At  the  same  time,  under  such 
circumstances,  the  patient  must  be  carefully  watched  on  account  of 
the  tendency  to  onanism. 

Case  11. — Maniacal  exaltation  during  the  puerperium. 

Mrs.  L.,  aged  28,  painter's  wife.  Her  mother  became  insane  at  the  age 
of  36,  during  the  puerperium;  one  sister  Avas  a  deaf-mute.  Patient  was  previ- 
ously healthy  with  the  exception  of  small-pox,  and  she  was  strong.  She  had  had 
her  first  child  at  the  age  of  IS,  and  her  second  at  the  age  of  20.  Thereafter 
she  had  four  children.  She  nursed  the  child  next  to  the  last  tAventy  months. 
She  was  reduced  by  frequent  births  and  nursing,  and  besides  the  family  was 
needy  and  had  trouble  in  gaining  sufficient  food.  During  the  last  pregnancy, 
which  lasted  until  the  2d  of  November,  1880,  the  patient  often  had  attacks  of 
dizziness  and  symptoms  of  mental  exhaustion.  The  birth  was  normal :  the 
patient  nursed  her  child  fourteen  days.     After  a  violent  shock  due  to  a  sudden 


318  SPECIAL  PATHOLOGY  AND  TIIl^RAPY  OF  INSANITY. 

illness  of  her  Imsband  on  tlic  loth  of  July,  she  bcc-anie  confuseil  and  l)i(ni<;lit 
home  playthings  instead  of  food  on  the  lOth.  Slie  became  sleepless,  delirious, 
and  saw  her  dead  parents,  the  protecting  spirit;  the  evil  one,  who  gave  forth 
frightful  odors;  and  the  N'irgin  Mary,  who  jnotected  her.  Tliose  about  her 
seemed  hostile,  and  she  wandered  around  confused  and  without  plan,  once  to 
the  water  and  another  time  witli  her  cliiid,  and  another  to  lior  pastor  to  con- 
fess.    On  the  niglit  of. November  'lid  she  tried  to  take  a  wardrobe  downstairs. 

"W'iien  admitted,  NunciiiIut  '22^1.  the  pucr|icral  inilial  ilcliiiinu  liad  ilisa])- 
peared.  The  patient  was  without  fear,  huid,  and  liad  insight  into  her 
delirium;  but  she  presented  symptoms  of  slight  maniacal  exaltation,  which 
gave  the  impression  of  a  stage  of  remission  of  an  acute  iiallurinatory  inicrperal 
mania.     Tlie  furtlier  conr.se  Justified  this  presumption. 

The  patient,  who  at  the  time  of  her  admission  manifested  causeless 
gayety,  sligiit  erotic  excitement,  inconstancy,  lively  play  of  facial  expression, 
abnormally  rapid  and  interrupted  flow  of  ideas,  as  indications  of  her  maniacal 
state,  remained  up  to  the  time  of  her  convalescence  in  the  stage  of  maniacal 
exalt-ation.  She  was  conlinimlly  gay,  lively,  and  all  impressions  were  for  her 
pleasant  and  ridiculous. 

She  took  pleasure  in  jokes  and  humorous  comparisons:  inished  herself 
forward  in  conversation;  played  the  coquette,  saying  she  was  in  love;  de- 
clared that  she  was  going  to  marry  another  man,  and  that  her  husband  could 
find  another  Avife.  She  wanted  to  marry  the  professor  or  the  doctor,  though 
this  was  not  in  earnest.  Her  consciousness  was  not  more  deeply  disturbed. 
She  was  quite  conscious  of  her  abnormal  condition,  but  slie  thought  that  she 
was  absolutely  faithful,  and  a  little  sinning  in  delirium  could  not  be  counted 
against  her.  Formerly  she  was  insane.  Patient  built  all  sorts  of  air-castles. 
She  was  inexhaustible  in  bad  witticisms,  and  her  thought  was  precipitate, 
often  erotic,  without  becoming  indecent.  She  had  to  sing  and  talk  in  order 
to  distract  other  patients.  She  had  no  longing  for  her  relatives,  who  were 
able  to  take  care  of  themselves.  Formerly  she  had  had  a  hard  time,  l)ut  now 
she  was  going  to  have  a  good  time  in  the  hospital.  She  was  filled  witli  desire 
for  food  and  drink.  At  the  beginning  she  was  restless  at  night:  with  better 
food  and  beer  and  wine  she  began  to  sleep. 

The  patient  is  of  medium  size,  witiiout  signs  of  degeneration,  and  with 
no  indication  of  vegetative  disturbances,  though  she  is  very  anemic.  Her 
general  state  is  much  reduced.  Uterine  involution  has  taken  place  normally. 
The  pulse  is  small  and  the  artery  underfilled. 

Occa.sionally  the  patient  recognizes  a  military  surgeon  who  visits  the 
hospital,  as  the  emperor;  another  gentleman  as  the  crown  prince.  There  were 
no  hallucinations  observed. 

Toward  the  end  of  December  the  patient  became  quiet  and  more  orderly, 
asked  about  her  relatives,  corrected  her  illusions,  and  asked  for  work.  She 
was  then  able  to  associate  with  other  patients  and  worked  diligently.  Visits 
from  relatives  had  a  favorable  effect.  The  return  of  the  menses  on  December 
21st  took  place  without  disturbing  her  convalescence.  The  treatment  in  this 
slight  case  of  puerperal  mania  was  limited  to  isolation,  good  food,  baths,  and 
preparations  of  iron.  She  had  gained  three  kilograms  during  her  time  of  treat- 
niont.     On  January  14,  18S1,  she  Avas  discharged  cured,  and  remained  well. 


^S^•  ('  1 1  ()  \  KUßOÖES— rilJMARY  CJURA IVLE  STATES.  3  ]  f) 

II.  FuKious  Maxia. 

Furious  luani.i  is  a  higher  stage  oi'  clevelopnioii  of  innuia,  iluiti 
maniacal  exaltation. 

The  idea  of  furious  mania,  originally  gained  from  the  external 
furious  conduct  of  tlie  patient,  must  ho  sul)mitted  to  scientific  limita- 
tion. Fury  is  a  jnere  symptom,  wiiilc  fiii'ious  mania  is  a  distinct 
2)athologic  state  occurring  in  the  course  of  mania.  Tlie  fury  of  the 
melancholic  due  to  fear,  the  fury  of  the  delirious  (epileptic,  hys- 
teric, alcoholic,  fehrile),  due  to  frightful  hallucinations,  is  not  to  be 
confounded  with  furious  mania.  The  distinctive  characteristic  of 
furious  mania  is  increased  rapidity  of  psychic  processes,  going  even 
to  complete  loss  of  control,  in  which  the  ego  of  the  patient  has  lost 
all  directive  poAver  and  is  no  longer  able  to  control  the  psychic  acts. 
With  this  there  are  signs  of  direct  excitation  of  the  organ  of  con- 
sciousness. 

In  the  psychomotor  centers  of  the  forebrain  these  consist  of 
irritative  processes  which  cause  motor  acts,  which,  though  they  pos- 
sess psychic  features,  are  still  without  purpose  or  end,  arise  uncon- 
sciously without  intervention  of  the  will,  and  therefore  must  be 
characterized  as  purely  impulsive  acts.  These  repress  more  and  more 
the  voluntary  acts  of  the  patient  in  maniacal  exaltation  based  on 
ideas  and  pleasurable  feelings.  Further  manifestations  to  be  men- 
tioned as  phenomena  of  excitemeht  that  are  seldom  wanting  are 
delusions  and  errors  of  the  senses.  Naturally,  owing  to  the  profound 
disturbance  of  the  psj^chic  organ,  there  is  pronounced  involvement 
of  consciousness.  A  closer  study  of  the  disease-picture  shows  that 
upon  the  affective  side  and  formally  there  is  greatly  increased  excit- 
ability (psychic  hyperesthesia),  as  result  of  which  all  impressions  that 
reach  consciousness  are  colored  v/ith  lively  affects. 

Here,  too,  as  in  maniacal  exaltation,  expansive  affects  predom- 
inate; but  affects  of  an  opposite  nature,  especially  those  of  anger, 
are  not  excluded.  Indeed,  there  are  rare  cases  in  which  the  affect 
of  anger  predominates  throughout  the  Avhole  course  of  the  disease 
(angry  mania).  These  clinical  differences  in  the  disease-picture  are 
partly  dependent  upon  original  anomalies  (tainted  cerebral  organi- 
zation) of  a  patient  naturally  choleric  and  of  irritable  character, 
partly  artificially  produced  by  restraint,  and  partly  a  reactive  mani- 
festation dependent  upon  frightful  delusions,  hallucinations,  and 
complicating  feelings  of  fear. 

If  an  emotional  state  "of  anger  be  due  to  any  of  these  factors, 
owing  to  the  greatly  increased  excitability,  secondary  painful  repra^ 


320  SPECIAL  PATHOLOGY  AM)  TllEltAPY  OF  IXSAMTY. 

duction  of  ideas  takes  place,  which,  however,  in  contrast  witli  agitated 
melancholia,  present  the  character  of  the  ilight  of  ideas  with  varia- 
tions in  the  train  of  thonglit.  Those  then  maintain  an  angry  emo- 
tional state.  Such  cases  of  pure  angry  mania  arc  the  most  infre- 
quent. Expansive  cases  are  much  more  frequent,  and  the  most 
frequent  are  those  of  a  mixed  form:  i.e.,  those  in  which,  with  the 
great  excitement  and  the  rapid  change  of  ideas,  together  with  un- 
limited association,  there  is  a  striking  variation  in  the  content  of 
the  most  varied  emotional  states  (variation  of  humor).  Since  the 
ego  is  powerless  in  the  face  of  this  excitement,  owing  to  the  great 
increase  of  all  psychic  activities  and  the  ahsence  of  all  inhibition, 
these  afPects  manifest  themselves  throughout  the  entire  domain  of 
expression  and  movement.  Thus,  foolish  joy  and  maniacal  exaltation 
alternate  with  phases  of  angry  excitement  and  painful  weejiing; 
singing,  whistling,  shouting,  and  hawling  altoriiate  with  angry  howl- 
ing and  fury.  Often  a  transitory  external  impression  or  some  thought 
suffices  to  change  the  emotional  state  into  an  opposite  one,  on  ac- 
count of  the  psychic  hyperesthesia. 

The  great  increase  in  the  rapidity  of  thought  leads  to  flight  of 
ideas ;  and  since  no  single  thought  can  be  retained  in  mind,  a  logical 
series  of  ideas  is  impossible,  and  the  result  is  incoherence  (overfilling 
of  consciousness;  association  of  ideas  due  only  to  assonance  and  allit- 
eration; spontaneous,  physiologic  production  of  ideas  independently 
of  association). 

Thus,  necessarily,  the  logical  association  of  ideas  and  the  gram- 
matic  form  of  speech  are  lost,  rragments  of  sentences,  disconnected 
words,  and  finally  mere  interjections  or  cries,  indicate  the  varying 
degree  of  the  maniacal  flight  of  ideas  and  incoherence. 

Owing  to  the  great  rapidity  of  thought,  apperception  is  imper- 
fect, and  therefore  illusions  are  facilitated. 

Hallucinations  may  occur  at  any  time  and  in  any  sensory  domain. 
They  are  very  frec^uent  when  the  course  is  acute,  especially  in  the 
visual  sphere. 

Almost  without  exception  there  are  delusions.  They  are,  for 
the  most  part,  connected  with  errors  of  the  senses,  but  they  may  be 
primordial;  least  frequently  they  arise  as  temporary  attempts  to 
exjjlain  states  of  consciousness  and  sensations.  Their  content  is 
infinite  in  variety,  but,  for  the  most  part,  of  an  expansive  nature 
(grand  delusions).  Frequently,  especially  in  women,  they  have  a 
sexual  coloring,  or  its  equivalent — a  religious  tinge.  Siich  delusions 
are:  of  being  the  Virgin  Mary;  of  being  overshadowed  by  the  Holy 
Ghost;   of  having  given  birth  to  Christ.     In  angry  mania,  delusions 


PSYCHONEUROSES— PRIMARY  CURABLE  STATES.  321 

of  persecution^  especially  of  a  demoniac  colorijig,  may  form  the  nu- 
cleus of  the  emotional  state. 

These  delusions  are,  owing  to  the  transitoriness  of  their  causes 
and  the  rapidity  of  thought,  which  allows  no  reflection,  desultory;. 
and  only  seldom,  or  in  mania  that  becomes  chronic,  do  they  lead  to 
a  lasting  change  of  consciousness,  with  possible  termination  in  sec- 
ondary delusional  insanity. 

The  psychomotor  sphere  presents  the  most  important  phenomena 
of  the  disease-picture,  and  these  have  given  the  disease  its  name. 
Aside  from  the  pauses  that  arise  from  exhaustion,  the  patient  is  in 
constant  activity,  and  there  is  no  voluntary  group  of  muscles  that  is 
not  brought  into  action.  The  motor  acts  of  the  patient  are  due  to 
various  causes.  In  transition  from  maniacal  exaltation  to  mania,  and 
during  the  remissions  of  mania,  there  may  be  formal  volitional  acts; 
but,  since  the  underlying  ideas,  owing  to  the  increasing  rapidity  of 
thought  and  of  cloudiness  of  consciousness,  become  less  and  less  clear, 
such  voluntary  acts  take  on  more  and  more  the  character  of  impulsive 
acts.  At  the  same  time  there  are  psychic  reflex  acts  due  to  joyous 
emotion  (dancing,  singing,  etc.),  or  to  fear  and  anger. 

At  the  height  of  the  disease  such  psychically  conditioned  motor 
acts  occur  only  rarely.  They  are  pushed  aside  by  impulsive  move- 
ments due  to  direct  irritation  of  the  psychomotor  centers;  at  the 
same  time  there  are  acts  due  to  delusions  and  errors  of  the  senses. 

Very  frequently,  too,  in  mania,  the  sexual  instinct  is  excited,  and 
cases  in  Avhich  this  predominates  are  often  called  satyriasis  in  males 
and  nymphomania  in  females. 

The  more  profound  disturbance  of  consciousness  as  compared 
with  that  of  maniacal  exaltation  allows  the  sexual  impulse  to  express 
itself  without  reserve:  in  the  forms  of  direct  attack  on  persons  of 
the  opposite  sex,  ojoen  onanism,  and  movements  of  coitus. 

Doubtless,  in  women,  the  following  should  be  regarded  as  equiv- 
alents: constant  spitting;  satisfaction  of  nature  in  the  presence 
of  the  physician;  smearing  the  body  and  walls  with  feces,  saliva, 
menstrual  blood,  and  urine;  obscene  scolding  of  nurses. 

The  disturbance  of  consciousness  is  extremely  varied  in  char- 
acter, in  general  more  marked  the  more  acute  the  course  of  the 
disease.  Memory  of  the  period  is  quite  parallel  with  its  degree.  In 
chronic  mania  memory  may  be  undisturbed;  but,  when  the  course 
of  the  disease  is  acute,  it  is  at  best  only  summary.  Complete  amnesia 
does  not  occur  in  true  mania. 

Physical  Symptoms. — Disturbance  of  sleep  is  a  constant  phe- 
nomenon.   It  may  be  Avanting  for  a  week  at  a  time.    Attacks  of  cere- 


332  SPECIAL  PATHOLOCY  AND  THERAPY  OF  IXSAXITY. 

bral  congestion  are  frequent,  and  are  sometimes  to  be  regarded  as 
causal  in  nature;  but  usually  tbcy  are  consecutive  phenomena  (active 
congestion  due  to  functional  cerebral  excitement  or  to  lessened  re- 
sistance, referable  to  vasoparesis). 

The  frequency  of  the  pulse  is  very  little  inlluenced,  when  the 
excessive  muscular  activity  is  taken  into  consideration.  In  spite  ot" 
violent  mania,  the  pulse  is  often  rather  slowed  than  accelerated,  and 
rather  small  than  full. 

The  body-temperature  is  normal,  sometimes  even  subnuriiial, 
since  the  increased  production  of  heat  by  forced  muscular  work  is 
more  than  compensated  for  by  the  increased  loss  of  heat  due  to 
insufiicient  clothing.  Any  considerable  and  continued  elevation  of 
temperature  above  38°  C,  if  it  cannot  be  referred  to  a  complicating 
physical  disease,  should  raise  the  question  whether  the  case  is  to  be 
regarded  as  one  of  mania,  or  one  of  acute  delirium,  or  whether  it  is 
not  a  state  of  psychomotor  excitement  dependent  upon  some  other 
organic  cerebral  disease. 

In  the  early  stages  of  mania  the  turgor  vitalis  is  increased.  The 
patient  looks  younger  and  fresher.  When  mania  has  continued  for 
a  long  time,  nutrition  and  strength  diminish,  and  this  may  go  on  to 
a  state  of  inanition.  Always  at  the  height  of  the  disease  there  is 
progressive  loss  of  weight.  The  secretions  may  be  perfectly  normal. 
Often  the  urine  is  abnormally  rich  in  phosphates;  a  very  frequent 
symptom  is  salivation,  which  accompanies  exacerbations  of  the  psy- 
chosis. 

Sensory  disturbances  play  but  a  small  part  in  cases  of  mania. 
Sometimes,  during  the  remissions,  patients  complain  of  headache, 
Any  anesthesias  that  occur,  especially  insensibility  to  cold,  which  is 
striking,  are  always  due  to  a  central  cause.  Sensorial  hyperesthesia 
is  not  infrequent. 

Motor  disturbances  in  the  infracortical  domain,  in  the  form  of 
cramps,  limited  muscular  twitchings,  grimaces,  etc.,  may  occur  as  a 
complication  at  the  height  of  severe  mania,  and  they  represent  transi- 
tions to  acute  delirium  and  other  cerebral  diseases. 

Feequenct. — Furious  mania  occurs  much  more  frequently  as  an 
independent  form  of  disease  than  as  a  symptomatic  form.  In  the 
latter  case  it  usually  has  a  sudden  outbreak,  acute  course,  and  occurs 
in  dementia  paralytica  and  other  cerebral  diseases  with  predominat- 
ing psychic  disturbance.  In  hysteria,  and  in  certain  forms  of  circu- 
lar insanity,  where  the  course  is  brief,  general  maniacal  symptoms 
alternate  with  symptoms  of  stupor  and  tetano-cataleptiform  mani- 
festations, 


PSYCnONEUi;(),SE8— PKTMARY  (J\J\IA\'.\A<:  STATES.  ;]2?> 

Origin  and  CoujisI':. — The  acute  and  chronic  cases  arc  to  Ijc 
differentiated : — 

(a)  Acute  mania  hists  from  a  Iv.w  (hiys  to  wc(!ks;  it  breaks  out 
suddenly,  after  previous  sensorial,  hut  not  mehmchfjlic  symptoms 
(headache,  congestion,  disturbed  sleep,  fear,  irritability).  There- 
after come  symptoms  of  maniacal,  and  usual  ii'ritabk',  exaltation, 
which  with  remarkable  rapidity  attain  the  heiglit  of  mania.  The 
more  acute  the  course,  the  more  profound  is  the  disturbance  of  con- 
sciousness. The  descent  from  the  height  of  the  disease  is  usually 
quite  rapid.  Symptoms  of  functional  exhaustion,  even  with  slight 
stupor,  constitute  the  transition  to  health. 

Acute  mania  often  runs  its  course  as  angry,  or,  at  least,  irritable, 
mania.  Angry  mania  runs  its  course  in  a  few  days,  but  recrudescence 
is  easy,  so  that  a  protracted  insanity  develops,  in  which  the  single 
angry  explosive  attacks  are  sharply  distinguished  from  the  remis- 
sions (periods  of  functional  exhaustion  with  irritability). 

/b)  Chronic  mania  lasts  months  or  a  year  or  more.  It  is  usually 
preceded  by  a  melancholic  prodromal  stage.  The  duration  of  this 
prodromal  stage  varies  from  a  few  days  to  a  few  months.  The  longer 
this  lasts,  the  longer  the  following  attack  of  mania  lasts. 

This  prodromal  stage  is  merely  indicated  or  wanting  in  puerperal  cases, 
in  cases  due  to  sudden  loss  of  blood,  and  in  cases  that  arise  during  con- 
valescence from  severe  febrile  diseases.  It  is  also  wanting  in  cases  due  to 
direct  cerebral  shock,  like  trauma  capitis  and  insolation,  and  in  mania  due 
to  alcoholic  excesses.  The  more  mania  appears  to  be  organic,  and  the  more 
it  seems  to  be  due  to  physical  causes,  the  more  frequently  this  prodromal 
stage  is  wanting.  This  stage  is  usually  that  of  melancholia  without  delusion, 
but  the  statement  of  Hagen  that  delusions  and  errors  of  the  senses  never 
occur  is  not  true.  The  symptoms  of  this  melancholic  prodromal  stage  are 
essentially  those  of  a  disturbance  of  psychic  and  general  physical  feeling 
( difficulty  of  mental  activity,  general  prostration,  heaviness  in  the  head, 
gastric  disturbances,  constipation,  etc.),  like  those  which  precede  the  outbreak 
of  a  severe  physical  disease,  especially  an  infection.  Out  of  this  condition 
psychic  depression  develops,  often  of  an  hypochondriac  character.  In  the 
further  course  there  is  painful  reflection  concerning  the  former  life,  which 
may  give  rise  to  self-accusation  and  disgust  of  life.  Frequently  this  stage 
passes  unobserved,  or  is  intentionally  concealed  by  the  patients,  who  know 
how  to  accomplish  this  or  who  know  how  to  explain  their  condition  rationally 
(Mendel). 

The  transformation  to  mania  is  usually  sudden ;  still,  it  is  never 
so  strikingly  so  as  in  circular  insanity.  Sometimes  there  is  a  period 
of  alternation,  lasting  hours  or  days,  in  which  melancholic  and 
maniacal  elements  are  mingled,  striving,  as  it  were,  for  a  mastery, 
until  the  maniacal  disease-picture  becomes  pure.    Sometimes  quickly. 


3'2i  SPECIAL  rATlIOI.OCY  AM)  TllJCnArY  OF  IXSAXITV. 

sometimes  slowl}-,  llic  mania  develops  out  of  this  maniacal  exaltation. 
The  impulsive  activity  takes  on  more  and  more  the  character  of  the 
ilight  of  ideas;  the  expansive  emotional  state  becomes  a  kaleidoscope 
of  the  most  opposite  emotional  states  of  excitement;  movements 
become  more  and  juore  impulsive  and  uncontrollable,  with  increasing 
disturbance  of  consciousness;  and  delusions  and  ballucinations  are 
added.  The  general  course  of  chronic  mania  exhibits  remissions  and 
exacerbations.  During  remissions  the  disease-picture  changes  to  that 
of  maniacal  exaltation,  which,  of  course,  is  often  covered  by  signs  of 
functional  exhaustion.  The  latter  may  be  of  a  painful  cbaracter; 
aiul  under  such  circumstances,  owing  to  the  great  excitability,  nio- 
roseness  and  explosions  of  anger  may  occur. 

The  Terminations  oe  Mania  are: — 

1.  Becovery} — Recovery  never  occurs  suddenly,  but  gradually, 
with  remissions  and  various  transitional  conditions.  A  sudden  cessa- 
tion of  mania  indicates  a  symptomatic  or  periodic  foundation. 

The  transitional  stages  to  recovery  may  be : — 

(a)  A  stage  of  melancholic  depression  like  that  which  charac- 
terized the  beginning  of  the  disease.  Such  a  manner  of  termination 
is  very  infrequent,  if  a  stage  of  exhaustion,  with  perception  of  mental 
insufticiency  due  to  exhaustion,  is  not  regarded  as  melancholia. 

(l)  A  stage  of  stupidity,  of  functional  dementia,  as  an  expres- 
sion of  profound  brain  exhaustion,  such  as  necessarily  follows  severe 
cases  of  chronic  mania,  or  such  cases  as  have  been  treated  by  bleed- 
ing. This  stage  lasts  sometimes  several  months.  Stationary  weight, 
or  but  slight  and  gradual  increase  of  it,  in  such  symptomatic  states 
of  dementia,  in  contrast  with  the  rapid  gain  in  weight  in  states  of 
terminal  dementia,  are  the  important  points  of  differential  diagnosis. 

In  general,  the  intensity  and  duration  of  this  state  of  slight 
stupor,  or  complete  dementia  due  to  states  of  exhaustion,  correspond 
with  the  intensity  and  duration  of  the  previous  mania,  and  with 
the  intensity  and  importance  of  the  causes,  among  which  an  original 
tainted  constitution,  abnormally  deficient  in  resistive  power,  must  be 
given  special  consideration. 

(c)  Passage  of  mania  through  a  state  of  diminishing  maniacal 
excitement,  Avith  simultaneous,  but  transitory,  symptoms  of  psychic 
weakness  ("moria"). 

(d)  Gradual  subsidence  of  the  mania,  the  remissions  growing 
more  pronounced  and  clear,  with  no  important  manifestations  of  in- 
tellectual weakness.     In  such  cases,  however,  often  the  emotional 


^Mendel,  "Die  Manie,"  p.  155,  eälimates  SO  per  cent. 


PSYCHONEUROSES— PRIMAHY  CURABLE  STATES.  325 

side  of  mental  life  is  gravely  implicated.  A  state  of  delicate  equilib- 
rium and  of  increased  emotional  irritability  exists,  whicb  easily  loads 
to  explosions  of  anger  and  relapses. 

The  prognosis  of  mania  is,  in  general,  favorable;  and  the  more 
favorable  the  more  acute  its  course,  when  the  nutritive  disturbances 
are  reparable  (anemia,  puerperium),  when  the  causes  are  sympathetic, 
and  when  the  patient  is  young  and  the  brain  not  too  much  burdened. 
At  the  same  time  it  should  be  said  that  severe  mania  but  seldom  per- 
mits a  complete  and  scientifically  satisfactory  recovery ;  slight  mental 
weakness  (emotional,  and  with  weakness  of  the  will)  often  indicates 
cure  with  defect. 

3.  Termination  in  a  secondary  state  of  mental  luealiness  (mental 
weakness  or  dementia  in  their  clinical  pictures;  infrequently,  sec- 
ondary delusional  insanity). 

3.  Termination  in  deatti^  due  to  exhaustion  or  to  intercurrent 
diseases;  to  injuries,  with  possible  fat-embolism  of  the  lungs  (Jolly); 
or  to  advance  of  the  cerebral  disease-process  to  the  intensity  of  acute 
delirium. 

Therapeutic  Indications.  —  1.  Isolation.  —  The  clinical  fact 
that  maniacal  states  are  states  of  cerebral  excitement,  especially  as- 
sociated with  hyperesthesia  of  the  psychic  and  sensorial  functions, 
demands,  as  the  first  indication,  psychic  and  cerebral  rest:  i.e., 
avoidance  of  all  lively  sense-impressions  and  all  psychic  irritation  in 
general.  This  object  can  be  attained  only  by  an  intelligent  isolation 
of  the  patient,  the  degree  of  which  must  correspond  with  the  degree 
of  cerebral  hyperesthesia.  In  many  cases  simple  isolation  is  sufficient 
to  promote  the  recovery  of  the  patient. 

This  isolation  saves  the  patient  from  excesses,  especially  in  alco- 
hol and  venery,  which,  were  they  indulged  in  Avith  freedom,  would  do 
great  harm. 

2.  Protection  of  the  patient  and  others  from  his  destructive  out- 
breaks. It  is  seldom  that  a  patient  injures  himself;  therefore 
padded  cells  are  not  necessary,  and,  besides,  they  cannot  be  kept 
clean.  Too,  the  maniacal  patient,  except  in  acute  mania  with  pro- 
foundly clouded  consciousness,  or  when  in  a  state  of  angry  emotion, 
is  not  so  dangerous  to  others  as  is  often  supposed.  Many  maniacs 
know  what  they  do,  and  retain  a  certain  amount  of  reason,  even 
when  they  are  incapable  of  controlling  their  acts.  The  belief  that 
maniacs  are  abnormally  strong  is  a  prejudice;  and  their  treatment, 
for  this  reason,  with  chains   and   camisoles  is   cruel.     Mechanical 


^  Mendel  (op.  cit.J  computes  5  pei-  cent,  mortality. 


33G  SPECTAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

restraint  is  onl}^  permissible  for  tliorapoutic  reasons,  wlien  the  hori- 
zontal position,  as  in  a  case  of  profound  anemia  of  the  brain,  or  in 
certain  cases  of  surgical  injuries,  is  necessary. 

An  attempt  to  diminish  the  movement  by  mechanical  restraint, 
and  thns- to  conserve  strength,  is  useless.'  The  patient  makes  more 
exertion  iu  a  camisole  than  when  left  to  himself.  j\[any  cases  of 
mania  are  actually  intensified  by  mechanical  restraint,  especially 
M-hen  an  effort  is  made  to  impress  them  by  it.  It  is  a  fact  that  the 
violence  of  mania,  "with  the  increasing  use  of  the  principle  of  non- 
restraint,  has  been  decidedly  diminished.  j\[aniacs  that  destroy 
everything  and  constantly  undress  themselves,  should  be'  left  naked 
in  a  well-warmed  cell;  or  seagrass  or  horsehair,  which  is  better,  may 
be  given  them  for  covering.  All  objects  should  be  taken  out  of  the 
cell.  In  a  few  cases,  hyoscine  or  duboisine  may  be  used  temporarily 
to  advantage.  Their  frequent  administration  is  contra-indicated  on 
account  of  their  effect  to  interfere  with  general  nutrition. 

3.  Mainienance  of  a  Stale  of  Good  General  Nutrilion. — Eaving, 
sleeplessness,  and  delirium  consume  the  patient's  strength;  and  this 
must  be  compensated.  Not  infrequently  does  the  final  result  depend 
upon  whether  the  nutritive  disturbance  of  the  brain,  after  the  mania 
has  passed  away,  is  reparable,  or  goes  on  to  atrophy.  Eich  nitrog- 
enous food  must  lie  given,  and  the  patient  allowed  to  eat  as  much  as 
possible,  with  milk  exclusively  to  drink. 

Jf.  Treatment  of  the  Cerebral  Excitement,  the  Tmpuhive  Movements, 
and  Sleeple^finem^. 

Formerly  tlie  violence  of  mania  was  taken  to  indicate  inflammatory  or 
congestive  states  of  the  brain,  and  an  attempt  was  made  to  apply  all  jjossible 
antiphlogistic  and  derivative  means  of  treatment. 

By  this  means  (venesection)  the  brain  was  only  exhausted  and  irritated 
(counter-irritation,  douches,  setons,  blistors)  and  the  digestion  destroyed 
(tartar  emetic,  sulphate  of  copper,  acetate  of  zinc).  All  these  remedies  should 
be  excluded  from  the  therapeutics  of  mania.  Bleeding,  especially  venesection, 
is  also  in  general  to  be  laid  aside. 

However,  congestions  are  frequent  and  worthy  of  consideration,  but  they 
are  Sue  to  disturba-nces  of  va.somotor  innervation  or  the  result  of  cerebral 
excitement.  Under  such  circumstances  bleeding  can  do  no  good,  but  rather 
increases  the  vascular  paralysis  and  poverty  of  the  blood.  The  very  circum- 
stance that  mania  arises  often  out  of  extreme  excesses  or  great  loss  of  blood 
(puerperiimi)  should  cause  us  to  be  \evy  economic  in  the  matter  of  the 
patient's  blood,  quite  aside  from  the  circumstance  that  jactitation,  sleepless- 
ness, and  loss  of  body-heat  aje  in  themselves  injurious  to  the  processes  of 
nutrition. 

The  symptomatic  treatment  of  mania  must  be  individualized, 
with  consideration  of  the  causes  and  the  presumable  pathologico- 


i>sYCHONEXTR0aEs— Primary  curable  r^i-ate^.         327 

anatomic  disturbances.  In  attacks  of  mania  with  decided  congestion, 
and  witli  symptoms  of  increased  reflex  excitability,  jerkings,  gnashing 
of  the  teeth,  contracted  pupils,  etc.,-  indicating  marked  cerebral  irri- 
tation,-bleeding  is  permissible;  but  this  should  never  be  general,  only 
local  (leeches).  In  such  cases,  too,  derivation  through  the  ailimentary 
tract  by  means  ai  calomel,  etc,-  may  suffice.  Ergotine,-  subcutane-* 
ously  or  internally,  also  deserve  consideration. 

As  a  rule,  however,  in  such  cases,  as  in  simple  congestive  attacks 
of  mania,  the  end  may  be  attained  by  ice-caps,  baths  with  ice  to  the 
head,  and  digitalis. 

In  cases  attended  by  predominant  sexual  excitement,  potassium 
bromide  in  doses  of  from  4  to  10  grams  is  useful. 

In  mania  due  to  alcoholic  excesses,  and  also  in  mania  that  pre- 
sents itself  in  the  clinical  picture  of  angry  affect,  opium  or  morphine 
is  indicated. 

In  mania  due  to  or  attended  by  cerebral  anemia,  brandy,  beer, 
wine,  and  occasionally  also  chloral  hydrate  are  the  best  remedies  to 
give  quiet  and  sleep.  Kest  in  bed  also  may  be  very  useful.  If  the 
maniacal  excitement  change  to  a  state  of  stuporous  exhaustion,  then 
rest  in  bed,  warmth,  rich  nourishment,  and  patience  are  the  principal 
means. 

In  the  stage  of  convalescence  the  patient  requires  most  careful 
watching  and  protection  from  irritation  of  all  kinds,  in  order  to 
avoid  a  relapse.  If  at  this  stage  there  is  great  irritability  and  tend- 
ency to  outbursts  of  anger,  morphine  is  the  best  means  to  shorten  the 
period  of  convalescence. 

Case  12. — Acute  angry  mania  initiated  by  an  outburst  of  anger. 

S.  W.,  aged  17;  her  father  was  a  drunkard.  Several  of  her  family  suf- 
fered with  convulsions.  She  had  typhoid  at  the  end  of  her  first  year,  and 
then  suffered  with  rickets.  She  learned  to  walk  the  second  time  only  when 
she  was  four  years  old.  She  developed  well  mentally,  but  was  always  given  to 
outbursts  of  anger,  irritable  and  sensitive.  The  menses  began  in  her  fifteenth 
year  without  disturbance. 

May  10,  1878,  she  entered  the  service  of  a  dressmaker  to  learn  the  trade. 
On  the  12th  she  got  angry  with  a  companion  who  asked  her  to  wash  the 
dishes.  She  thought  this  was  a  graA^e  insult,  and  became  violently  angry.  At 
that  time  the  patient  was  having  her  menses.  Her  anger  increased.  She  be- 
came sleepless,  and  thought  constantly  of  her  dispute  with  her  companion. 

On  the  19th  she  visited  a  family  of  friends,  and  immediately  began  to 
talk  of  her  trouble,  seeming  to  be  confused  and  dangerously  excited;  rea- 
soned with,  she  became  imcontroUably  angry,  scolded,  swore,  declaring  that 
she  was  injured  by  everybody,  and  she  ran  out  and  came  home  late  in  the 
evening  with  flushed  face,  scolding  and  saying  that  she  would  n'ot  allow  herself 


328  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

to  be  ruled  by  anybody.  She  did  not  sleep,  ate  nothing,  tried  to  leave  the 
house,  and,  whun  an  attempt  was  made  to  restrain  her,  she  struuk  everybody 
around. 

On  admission  the  patient  was  in  the  state  of  angry  mania.  Her  speech 
was  of  all  kinds  of  un])leasant  things  and  disconnected,  witli  lively  gesticula- 
tion. Everj'  attempt  to  quiet  her  only  increased  her  excitement.  She  poured 
forth  a  torrent  of  violent  language  on  all  around  her;  said  she  wa.s  no  longer 
sick,  though  the  night  before,  on  account  of  an  insult,  she  had  had  an  attack 
of  insanity,  her  head  luad  felt  hot,  and  she  could  not  sleep.  When  an  attempt 
was  made  to  undress  her,  she  became  violently  angry,  spat,  kicked,  twisted 
about  as  best  she  could,  and  threatened  to  expose  everything  in  the  news- 
paper. She  would  not  stay  with  such  fools,  and,  if  she  was  to  stay,  then  she 
nuist  be  cared  for  in  a.  noble  manner. 

The  patient  was  remarkably  short  and  undeveloped.  Her  thorax  and  the 
bulged  cranium  with  prominent  frontal  and  parietal  protuberances,  indicated 
the  early  rickets.  Also  the  teeth  were  irregularly  placed  and  grooved;  the 
vegetative  organs  presented  no  disturbance.  Pulse,  100,  full,  quick;  weight, 
31.5  kilograms. 

The  patient  remained  at  the  heiglit  of  angry  mania  until  the  end  of 
June.     She  slept  little,  and  was  reduced  to  29  kilograms  in  weight. 

Intensified  feeling  of  self-importance,  which  found  its  expression  in  af- 
fected speech  and  attitude  and  grand  airs,  now  and  then  attended  with  evi- 
dence of  eroticism,  and  coquetry,  formed  the  most  striking  symptoms  during 
periods  of  remission.  The  patient  was,  for  the  most  part,  in  angry  excitement. 
She  scolded,  raved  about  in  her  cell,  and  was  destructive;  thought  those  about 
her  hostile,  and  was  extremely  confused  in  thoughts,  which,  for  the  most  part, 
concerned  former  insults,  dissatisfaction  wdth  food,  care,  isolation,  etc. 

Injections  of  morphine  had  a  calming  effect,  but  did  not  overcome  this 
condition.  At  the  end  of  June  the  explosions  of  anger  became  less  frequent, 
and  there  were  longer  pauses  of  exhaustion.  The  patient  slept  much  and  took 
the  food  regularly  that  she  had  formerly  refused;  weight  increased  rapidly  to 
3Ü  kilograms.  Now  and  then  there  were  still  slight  indications  of  angry 
excitement  that  passed  off  spontaneously,  or  after  an  injection  of  morphine. 
The  patient  passed  the  greater  part  of  July  in  bed,  quiet,  exhausted,  and  talk- 
ing little.  In  August  she  gained  complete  insight  into  her  disease  and  re- 
gained her  former  strength.  In  September  she  was  discharged  completely 
cured.     She  weighed  at  this  time  41.5  kilograms. 

Case  13. — Mania  with  occasional  nymphomania. 

Miss  S.,  aged  22,  official's  daughter,  comes  of  a  tainted  family;  mother's 
father  was  exalted;  mother's  brother  insane;  father's  brother  eccentric; 
father's  sister  and  brother  insane. 

The  patient  developed  normally,  and  was  free  from  all  signs  of  taint. 
At  the  age  of  9  she  had  typhoid  with  delirium.  At  the  age  of  15,  menses 
came  on  with  some  trouble,  and  thereafter  recurred  regularly.  For  some  time 
she  had  been  chlorotic  and  required  much  sleep. 

In  the  middle  of  May,  1877,  she  became  depressed  without  appreciable 
cause.  She  was  shy,  silent,  had  precordial  distress,  and  complained  of  psychic 
anesthesia,  disgust  of  life,  and  dullness  in  her  head. 


PSYCHONEUROSES— PRIMARY  CURABLE  STATES.  339 

On  June  Qui  the  melancliolic  depression  changed  to  a  maniacal  condition. 
She  became  gay,  cliangeable,  taliiative,  busy,  and  occupied  with  ideas  of 
marriage,  home,  and  fine  clothing.  Almost  all  night  she  would  play  on  the 
piano,  became  very  sensitive  and  irritable,  complained  of  headache,  and  looked 
congested.  Her  tongue  was  coated.,  She  had  no  desire  for  food,  and  was 
constipated.  The  extremities  were  cool,  pulse  small  (80),  the  pupils  of  medium 
size,  reacting  to  light.  Occasionally,  for  an  hour  or  so,  she  would  sing, 
whistle,  and  laugh.    -By  wet  packing,  several  hours  of  sleep  were  obtained. 

With  continued  violent  congestions  (ergotine  was  unsuccessful,  even  with 
the  use  of  an  ice-bag  to  the  head),  on  the  14th  the  patient  reached  the  height 
of  mania,  so  that  it  was  necessary  to  send  her  to  the  hospital.  On  admission 
she  was  without  fever,  weighed  49  kilograms;  tall,  slim  form.  No  congestion; 
pulse,  48,  small,  quick.  No  signs  of  degeneration.  No  vegetative  disease.  In- 
tercostal neuralgia  on  the  left  side.  Absence  of  the  hymen.  Relaxation  of 
the  vaginal  mucous  membrane,  moderate  fluor  albus,  lateral  version  of  the 
uterus.  Eyes  brilliant,  profuse  salivation,  lively  change  of  facial  expression. 
The  patient  becomes  joyful,  singing  and  crying.  Flight  of  ideas.  The  de- 
lirium is  concerned  with  erotic  subjects. 

She  removes  her  clothing  and  reproaches  the  physicians  severely.  Placed 
in  bed,  she  boxes  the  ears  of  the  nurses;  throws  herself  about.  She  is  sleep- 
less, confused,  and  dances  about  all  day.  She  talks  of  love,  sings,  rhymes, 
smears,  makes  movements  of  coitus,  and  strikes  around  her.  Packing  and 
baths  bring  only  a  few  hours'  sleep.  She  walks  about  naked,  tears  everything, 
talking  all  the  time,  but  never  finishes  a  sentence.  She  speaks  all  the 
languages  she  knows,  mixing  them  all  together.  With  this  there  is  inclination 
to  rhyming  and  distortion  of  words. 

She  thinks  she  is  married,  the  wife  of  the  physician,  and  busies  herself 
about  an  infant.  At  the  time  of  her  regular,  but  scanty,  menses,  she  is  nym- 
phomaniacal and  cannot  be  approached.  At  such  times  she  smears  herself 
with  saliva,  feces,  and  menstrual  blood,  stands  on  her  head,  and  is  salivated. 

The  course  presents  but  slight  remissions.  Sleep  is  induced  by  variation 
in  the  use  of  chloral  hydrate  and  packing,  which  have  an  excellent  hypnotic 
effect.  The  patient  does  not  sleep  spontaneously.  She  has  numerous  visual 
hallucinations,  especially  at  night.  Blackmen,  fantastic  forms,  etc.,  surround 
and  disquiet  her.  Owing  to  motor  unrest,  the  patient  cannot  eat  spontane- 
ously. The  confusion  continues;  the  general  state  of  nutrition  sinks  de- 
cidedly (weight,  45  kilograms  at  the  beginning  of  January,  1878).  At  the  end 
of  January  the  patient  comes  to  herself  out  of  her  severe  mania,  complains  of 
headache,  pain  in  the  stomach,  intercostal  neuralgia,  and  wishes  to  know  how 
long  she  has  been  here,  and  whether  she  has  had  cerebral  typhoid.  She  is  still 
somewhat  confused,  and  still  thinks  she  is  the  wife  of  the  physician.  Still, 
during  hours  or  days,  she  has  maniacal  relapses,  especially  at  the  period  of 
the  menses,  and  gives  evidence  of  temporary  nymphomaniacal  excitement. 
Thereafter  there  are  signs  of  mental  exhaustion,  listlessness,  tendency  to 
emotional  excitement,  with  childish  action,  great  irritability,  and  inclination 
to  childish  play.  The  remains  of  erotic  excitement  are  indicated  by  lack  of 
modesty  before  the  jDhysicians.  Her  state  of  general  nutrition  improves  grad- 
ually, until  she  weighs  47  kilograms.  At  the  beginning  of  March  the  patient 
becomes  quiet,  orderly,  and  decent.  She  has  complete  consciousness  of  her 
disease,  and  with  distress  remembers  the  events  of  her  sickness. 


330  SPECIAL  PATHOLOGY  AND  THERAPY  Of  INSANITY. 

The  menses  in  the  niiildle  of  Maixh  pass  with  the  \ise  of  8  grams  of 
potassium  bromide,  with  only  slight  excitation  and  erotic  excitement.  The 
patient  feels  very  tired,  languid,  and  emotional,  and  has  no  int-lination  to 
occupy  herself. 

At  the  beginning  of  April  these  last  indications  of  the  disease  pass  away.- 
Her  weight  increases  to  5Ü  kilograms.  The  middle  of  April  she  is  discharged. 
On  a  visit,  in  the  middle  of  May,  the  patient  had  attained  normal  weight  of  ÜÜ 
kilograms. 


CHAPTER  III. 
Stupidity,  or  Primary  Curable  Dementia. 

The  clinieo-psychologic  characteristic  of  this  psychoneurosis 
is  difficulty  in  the  activity  of  the  psyehii-  functions,  whicli  may  attain 
the  degree  of  absolnte  arrest;,  with  simultaneous  absence  of  emotional 
accomi^animent. 

Vasomotor  anomalies  of  innervation  (vascular  spasm,  vascular 
paralysis),  disturbances  of  motor  innervation  (called  catatonic),  and 
episodically  states  of  psychomotor  excitement,  as  well  as  errors  o£ 
the  senses,  may  complicate  the  stupor.  Owing  to  the  occurrence  of 
these  complications  in  the  disease-picture  (delusional  stupor),  there 
are  clinical  transitions  to  the  form  of  primary  hallucinatory  insanity. 

These  states  of  retardation  or  suppression  of  psychic  activity 
are  different  from  the  anomalies  that  occur  in  acquired  idioc}'',  and  in 
contrast  with  the  intellectual  incapacity  of  melancholia  attonita  due 
to  an  arrest  of  the  power  of  reaction.  They  have  no  emotional  base 
and  constitute,  as  compared  with  the  state  of  exhaustion  after  mania, 
which  takes  on  the  form  of  stupor,  primary  conditions.  Again,  in  con- 
trast with  states  of  progressive 'primary  dementia  (senile,  apoplectic, 
etc.),  which  depend  upon  grave  organic  changes,  they  are  curable 
states. 

As  the  conditions  upon  which  the  suspension  of  the  activity 
of  the  psychic  organ  depends,  there  may  be  cere1)ral  exhaustion,  shock 
due  to  psychic  trauma  (affect),  or  physical  shock. 

In  the  first  two  instances,  there  must  be  a  predisposition  in  lack 
of  cerebral  resistive  power,  either  original  or  due  ,to  various  causes 
that  have  rendered  the  brain  irritable  and  easily  exhausted. 

Pathogenically  and  clinically,  cases  may  be  differentiated  into 
the  stupor  due  to  inanition,  to  emotional  shock,  and  to  head  injury. 

(a)  Stupidity  Due  to  Exhaustion  of  the  Psychic  Organ. 

This  is  the  most  frequent  clinical  form.  Defective  renewal  of 
the  elements  of  force  and  disturbance  of  their  transformation  into 


PS YCHONEUROSES— PRIMARY  CURABLE  STATES.  33t 

living  force  are  the  probable  cauöos  of  the  bindranco  of  fnnr'iion, 
which  may  even  go  so  far  as  arrest  of  psychic  activity. 

Without  exception,  the  victims  of  this  state  of  exhaustion  are 
weak,  delicate,  neuropathic,  youthful  individuals.  I  have  found  with 
remarkable  frequency,  as  further  indications  of  taint,  microcephalic 
and  rachitic  forms  of  the  cranium.  This  form  of  mental  exhaustion 
does  not  appear  to  occur  after  the  age  of  30.  A  further  favorable 
condition  for  its  development  is  rapid  growth  during  the  years  of 
puberty,  especially  in  persons  subjected  to  mental  and  physical  over- 
strain and  insufficient  food.  Not  infrequently  this  condition  repre- 
sents the  acme  of  severe  cerebrasthenia. 

The  exciting  causes  are  principally  the  puerperium,  with  great 
loss  of  blood;  grave  acute  diseases,  especially  typhoid;  and  sexual 
excesses,  especiall}^  onanism.  To  this  group  of  stuporous  insanity 
due  to  exhaustion  and  disturbed/  nutrition  probably  belong  also  case,^ 
due  to  extirpation  of  the  thyroid  (cachexia  strumipriva)  and  intoxica- 
tion with  carbonic  oxide  gas. 

In  kind,  the  state  of  postmaniacal  stuporous  exhaustion  is  also 
to  be  reckoned  in  this  group.  Eepeatedly  I  have  seen  this  picture  of 
stupidity  artificially  produced  as  a  result  of  treatment  of  melancholia 
and  mania  by  means  of  bleeding  (venesection,  leeches).  The  devel- 
opment of  the  disease-picture  is  gradual.  Erom  day  to  day  the 
patient  becomes  slower  and  duller  in  his  thought  and  action;  he 
remains  as  if  dreamily  sunk  in  thought  for  hours  at  a  time  in  the 
same  place,  and  falls  asleep  at  his  work.  After  a  few  days  or  weeks 
he  sinks  into  a  state  of  stuporous  dementia,  in  which  he  is  scarcely 
any  longer  conscious  of  himself  or  the  external  world,  devoid  of  all 
spontaneity,  and  living  only  a  vegetative  life.  The  patient  must  be 
forced  to  do  everything,  even  to  attend  to  the  necessities  of  nature. 
He  does  not  notice  food  set  before  him.  It  must  be  placed  in  his 
mouth  that  at  least  reflex  activity  ma}^  assert  itself,  and  swallowing 
take  place. 

The  countenance  is  confused,  expressionless;  the  eyes  glassy, 
staring  into  space.  The  pupils  are  dilated  and  react  lafily.  The  skin 
reflexes  are  greatly  reduced,  but  the  deep  reflexes  are  usually  mark- 
edly increased.  Sensibility  is  always  reduced,  and,  for  the  most  part, 
entirely  absent;  so  that  even  powerful  electric  irritation  makes  no 
impression. 

The  muscle-tone  is  reduced,  the  attitude  relaxed.  No  resistance 
is  offered  to  the  efl:orts  of  others.  In  rare  cases  there  are  episodic 
states  of  tonicity  of  the  muscles,  which  may  be  in  a  cataleptiform 
condition.    In  severe  cases  there  is  the  tremor  of  inanition. 


333  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

If  it  be  possible  to  induce  the  patient  to  put  out  the  tongue,  it 
is  seen  to  be  treniulons,  usiiall}'  with  fibrillary  twitching  of  the  orbic- 
ular muscles.  The  heart's  action  is  weak,  with  dull  sounds;  the 
pulse  is  usually  slow,  small,  tardodicrotic,  or  monocrotic.  If  the 
patient  be  led  around,  if  he  is  shouted  at,  the  pulse  becomes  more 
frequent.  The  extremities  are  usually  cool,  even  cyanotic.  If  the 
patient  remain  for  hours  at  a  time  in  a  standing  position,  there  is 
edema  of  the  feet,  which  rapidly  disappears  in  the  horizontal  position. 
On  the  other  hand,  in  the  morning  on  awaking  the  face  is  often 
slightly  cyanotic. 

The  body-temperature  is  subnormal.  In  spite  of  abundant  ad- 
ministration of  food,  nutrition  and  weight  sink  decidedly.  Kepeat- 
edly  I  have  found  differences  of  ten  kilograms  between  the  weight 
on  admission  and  the  weight  at  time  of  discharge. 

Constantly,  at  the  height  of  the  disease,  an  increase  of  phos- 
phates in  the  urine,  often  enormous,  has  been  observed.  The  pro- 
found disturbance  of  nutrition  shows  itself  in  the  dry  skin.  BroAviie 
also  noticed  in  his  patients  tendency  to  decubitus.  In  women,  the 
menses  cease  during  the  disease.  Owing  to  the  venous  stasis,  there 
is  not  infrequently  intestinal  and  uterine  catarrh. 

Cases  dependent  npon  onanism  are  characterized  by  their  development 
out  of  neurasthenia  with  nosophobia  and  symptoms  of  neurasthenia,  especially 
spinal  irritation;  so  that  these  patients  in  the  deepest  stupor  react  still  to 
pressure  over  the  spine.  There  are  further  not  infrequently  catatonic  symp- 
toms (tension  and  stiffness  of  the  muscles;  local  tonic  and  clonic  cramps, 
which  may  even  become  epileptifonn),  occasional  olfactory  hallucinations, 
and  raptus-like  outbreaks. 

Eespiration  is  superficial  and  insufficient.  In  consonance  with 
the  profound  disturbance  of  consciousness  the  patient  is  unclean  and 
the  saliva  runs  from  the  mouth. 

The  course  of  stuporous  insanity  as  an  expression  of  brain  ex- 
haustion is  remittent  with  exacerbations,  for  there  may  be  for  hours 
or  days  at  a  time  traces  of  mental  activity,  power  to  speak,  to  move, 
and  perception  of  impressions,  in  contrast  witli  the  state  of  dullness, 
stupidity,  and  absence  of  reaction.  Exacerbations  or  complications 
may  express  themselves  in  complete  stupor. 

Episodically  there  may  be  frightful  confusion  with  blind  im- 
pulses (due  to  complicating  hallucinations  or  cloudy  apperception  o£ 
the  helpless  painful  state),  as  infrequent  intercurrent  manifestation 
of  states  of  psychomotor  excitement,  lasting  hours  or  days,  in  which 
the  patient  sings,  whistles,  talks,  runs  about  aimlessly,  commits 
impulsive  acts,  tears  his  clothing,  and  occasionally,  also,  becomes 


PSYCHONEUROSES— PIllMARY  CUJlAJiLI*:  STA11=:S.  ?,?,?, 

aggressive  toward  others.  Sucli  states  of  excitement  must  not  Ije 
confounded  with  mania. 

If  the  malady  take  a  favoral)lc  course,  remissions  become  more 
prolonged  and  perfect.  The  expression  becomes  livelier;  the  patient 
begins  to  speak  a  few  words  and  sentences,  and  at  first  begins  to 
make  imitative  movements  which  later  become  spontaneous.  He 
now  also  begins  to  experience  a  painful  knowledge  of  Jiis  psychomotor 
incapability.  These  signs  of  improvement  take  place  irregularly, 
sometimes  followed  by  states  of  temporary  exhaustion.  Eecovery 
occurs  very  gradually,  with  improvement  of  general  nutrition,  de- 
cided increase  in  weight,  and  the  disappearance  of  the  circulatory  dis- 
turbances and  the  excess  of  phosphates  in  the  urine,  and  a  return 
of  normal  temperature.  The  memory  for  the  period  of  the  disease 
is  wanting,  or  only  very  summary.  The  disease  may  extend  over 
some  months.  The  cases  due  to  loss  of  blood  seem  to  be  the  ones 
to  recover  most  quickly. 

The  prognosis,  owing  to  the  youth  of  the  patients  and  the 
functional  character  of  the  psychosis  usually  is  favorable.  In  rare 
cases  functional  exhaustion  j)asses  on  to  irreparable  dementia.  Still 
less  frequently  there  is  a  fatal  termination  due  to  consumption  or 
pneumonia. 

The  etiology  and  symptoms  of  the  disease  point  to  a  state  of  profound 
anemia  of  the  psychic  organ.  Too,  Aldridge's  findings  with  the  ophthalmo- 
scope, with  Avhich  my  own  observations  accord,  point  to  anemia.  In  the  later 
stages  Aldridge  foimd  edema  of  the  fundus.  In  two  fatal  cases  reported  by 
Browne  there  was  venous  hyperemia  of  the  pia  in  one,  and  in  the  other  ad- 
vanced edema  of  the  pia  and  atrophy  of  a  few  gyri.  Emminghaus  found,  in 
one  case  of  acute  dementia  after  fever,  cloudy  swelling  of  the  ganglion-cells 
of  the  cortex. 

The  correct  diagnosis  of  this  state,  Avhich  was  formerly  con- 
founded with  melancholia  attonita,  and  even  Avith  idiocy,  is  of  the 
greatest  importance.  In  idiocy  no  mistake  is  possible,  if  the  history 
is  taken  into  account.  From  primary  progressive  dementia,  it  is  to 
be  distinguished  by  the  sudden  motor  disturbances  that  occur  as  ex- 
pression of  severe  organic  disease  of  the  brain  (apoplexy,  atheroma, 
etc.),  as  well  as  by  the  age. 

Difficulties  in  diagnosis  may  be  occasioned  by  cases  of  multiple 
and  diffuse  sclerosis  of  the  brain,  which  likewise  occur  most  fre- 
quently in  youth.  With  reference  to  the  first,  the  diagnosis  will  be 
cleared  up  by  the  relative  limitation  of  the  psychic  paralysis  with 
long-retained  emotional  and  higher  ethic  functions;  the  irritable 
weakness  of  the  emotional  life;   the  number  of  motor  and  especially 


•5;U  SPECFAL  PATHOLOCJY  AND  TIIKUAPY  OF  INSANITY. 

spinal  disturbances  (alaxia,  intention  tremor,  nuismlar  rigidity,  ^vv.xi 
increase  of  the  deep  reilexes,  ete.),  the  dysarthria,  nystagnms,  etc. 

The  dilferenliatiun  of  stupidity  as  a  psychoneurosis  from  pri- 
mary progressive  cK'nientia  ihie  to  dill'use  sclerosis  is  to  be  made 
only  l)y  observing  the  course  of  the  disease. 

The  following  points  are  of  dill'erential  diagnostic  value  with 
reference  to  melancholia  with  stu[)(M-:  In  primary  stu[)i(lily  the 
beginning  is  nsually  sudden;  in  melancholia  with  stupor  it  gradually 
develops  out  of  ordinary  melancholia.  In  stupidity  there  is  absence 
of  feeling;  in  melancliolia  liiere  is  an  exquisite  painful  state  of 
feeling.  In  the  one  there  is  the  demented,  stupid  expression;  in  tlie 
other,  an  apprehensive  strained  expression.  In  primary  dementia 
the  activity  of  the  voluntary  centers  is  greatly  reduced,  expressed 
in  relaxed  attitude,  reduced  muscle-tone,  absence  of  expressions 
of  the  Avill.  and  want  of  passive  resistance;  in  melancholia  with 
stupor,  on  the'  other  hand,  there  is  a  peculiar  state  of  tension  of  the 
muscles,  which  is  greatly  increased  by  efforts  to  make  passive  move- 
ment. In  stupidity  there  are  occasional  states  of  psycho-automatic 
excitement;  but  in  melancholia  there  are  not  infrequently  explosive 
reflex  acts  that  overcome  the  tension  and  psychomotor  inhibition, 
which  ma}^  lead  to  acts  of  violence  against  others  or  against  the 
patient  himself.  In  stupidity  there  is  anesthesia  of  apperception, 
while  in  melancholia  sensibility  remains,  manifest  in  the  intensity  of 
tension  even  to  the  degree  of  tetany,  and  the  facial  expression  due  to 
sensory  irritation.  In  the  one  case,  consciousness  is  absent  with 
amnesia  for  the  period  of  the  disease,  while,  in  the  other,  conscious- 
ness is  occupied  only  by  painful  ideas,  and  there  is  quite  perfect 
memory  of  the  events  of  the  disease.  In  the  first  case,  again,  there 
is  inability  spontaneously  to  take  food,  due  to  weakness  of  appercep- 
tion, while  in  the  other  there  is  positive  refusal  of  food  on  account  of 
delusions  and  feelings  of  disgust,  with  decided  loss  of  body-weight.  In 
the  first  case,  sleep  is  usually  good,  while  in  the  other  there  is  sleep- 
lessness. On  the  one  hand,  the  pulse  is  lazy,  slow,  and  soft,  while, 
on  the  other,  it  is  quick  and  the  artery  often  wire-like.  In  stupidity 
there  is  coolness  of  the  extremities,  cyanosis,  and  edema,  which  occur 
only  in  the  later  stages  of  melancholia;  and  likewise  there  is  great 
uncleanliness  in  stupidity,  contrasting  with  cleanliness  and  retention 
of  the  excretions  due  to  increased  innervation  of  the  sphincters  in 
melancholia.  In  the  first  case,  finally,  there  is  slow'  convalescence, 
while  in  melancholia  recovery  occurs  sometimes  suddenly. 

The  treatment  of  this  condition  has  for  its  object  the  restoration 
of  the  functions  of  the  cortex,  interfered  with  by  profound  disturb- 


PSYCITONEUROSES— Pi;iMAi:y  fiUKABLE  STA'M-IS.  ',]?,:^ 

ance  of  ruitriiion,  hy  means  of  frcsli.  air,  rich  food,  wine,  herjr,  rest, 
the  stiniuhition  of  respiration,  and  the  avoidance  of  unnecessary  loss 
of  body-heat.  Eest  in  bed  at  the  height  of  the  disease  is  imperatively 
demanded.  Watching,  to  prevent  onanism,  which  occurs  frcqiienlly 
enough,  is  necessary.  Iron,  arsenic,  nwx  vomica,  and  preparations  o(: 
quinine,  codJiver-oil,  and  malt  are  indicated.  Symptom atically,  re- 
flex stimulation  of  vascular  innervation  may  be  furthered  by  Avet,  but 
not  too  cool,  slapping  and  rubbing  of  the  skin.  Too,  electric  massage 
and  general  faradization  deserve  consideration  as  tonics  and  means 
of  promoting  metabolism  and  respiration. 

Crichton  Browne  praises  the  effect  of  central  galvanization  (five 
to  twenty  elements).  A  further  point  requiring  care  in  the" convales- 
cence of  these  patients,  who  so  easily  become  fatigued,  is  minute 
attention  to  the  amount  of  mental  and  physical  activity  allowed  them. 

Case  14. — Stupidity  due  to  enfeebling  physical  causes. 

F.,  aged  20,  blacksmith;  formerly  an  industrious,  good,  and  intelligent 
worker,  he  was  brought,  on  February  25,  1881,  by  his  employer  to  the  psychi- 
atric clinic.  The  patient,  who  came  of  a  tainted  family,  but  Avho  had  never 
been  decidedly  ill,  had  worked  in  his  last  place  from  July  to  Christmas,  1880, 
with  satisfaction,  and  he  was  always  pleasant  and  gay.  From  that  date  he 
was  peculiar.  At  night  he  shut  himself  up  in  his  room,  was  aroused  with  diffi- 
culty in  the  morning,  sleepy,  yaAvned  much,  said  but  little,  neglected  his  work, 
and  stood  about  staring  dreamily  into  space.  During  the  last  few  weeks  he 
had  been  silent,  ate  less  and  less,  and  liked  best  to  stay  in  his  room  on  the 
bed.  He  forgot  to  eat,  neglected  his  work,  finally  became  entirely  passive,  and 
reacted  only  slowly  to  the  loudest  shouts.  With  difficulty  he  could  be  induced 
to  say  that  something  was  wrong  in  his  head. 

On  admission  the  patient  is  stupid  and  inert.  He  allows  himself  to  be 
put  in  bed,  and  seems  to  perceive  nothing.  He  allows  himself  to  be  fed 
without  resistance,  does  not  speak,  and  leads  a  purely  vegetative  existence. 
After  a  few  days,  and  after  repeated  questions,  in  a  Ioav  and  interrupted  voice 
he  gives  some  notes  about  himself.  Concerning  his  last  place,  and  what  is 
going  on  in  his  thoughts,  nothing  can  be  learned. 

The  patient  is  a  slim,  tall  boy  (180  centimeters),  of  delicate  constitution, 
much  reduced  in  general  condition,  and  very  anemic.  His  eyes  have  a  neuro- 
pathic, swimming  expression.  His  skull  is  normally  formed  (circumference, 
55  centimeters);'  features  delicate  and  somewhat  feminine;  genitals  well  de- 
veloped. The  pelvis  approaches  the  feminine  type  (diameter  between  the 
anterior  superior  spines  of  the  ilii,  29.5  centimeters)  ;  glance  and  expression 
fatuous;  pupils  equal,  of  more  than  mediiun  size,  reacting  lazily.  The  vege- 
tative functions  are  undisturbed;  turgor  vitalis  is  wanting.  The  extremities 
are  cool  and  cyanotic.  The  urine  contains  enormous  quantities  of  earthy 
phosphates;  the  skin  is  dry  and  roiigh;  the  pulse  is  soft,  slow,  monocrotic, 
and  easily  compressed.  S^ensibility  of  the  cutaneous  surface  is  much  reduced. 
Only  strong  faradic  stimuli  cause  the  patient  to  react  in  painful  facial 
expression.  The  limbs  are  relaxed,  muscle-tone  reduced,  and  the  respiration  is 
superficial.     The  pulse  averages  80;    out  of  bed  it  rises  to  100.     Temperature^ 


336  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

36°  to  3G.4°  C.  (Treatment:  rest  iu  Ijcd.  rieli  food,  wine,  and  iron.)  Weight 
on  admission,  57.5  kilograms. 

The  patient  remains  in  his  stupidity  and  slate  of  absonco  of  reaction 
until  the  end  of  ISIartdi.  Fi-om  that  time  on  he  shows  traces  of  returning 
mental  activity;  tlie  expression  becomes  livelier.  He  now  and  then  laughs. 
When  persistently  questioned,  it  is  learned  that  he  is  better.  The  patient  be- 
comes clean,  and-  commences  to  carry  out  movements  to  which  he  is  com- 
manded, slowly,  often  hesitatingly,  as  if  he  had  to  think  how  this  or  that  were 
done.  Spontaneous  acts  are  limited  to  the  taking  of  food  placed  before  him 
and  attention  to  the  necessities  of  natiirc. 

Nutrition  and  circulation  slowly  improve.  When  the  luilicnt  is  out  of 
bed,  lie  immediately  shows  symptoms  of  cardiac  weakness,  and  his  extremities 
become  cyanotic  and  cold.  The  beginning  of  May  turgor  vitalis  returns,  the 
heart's  action  becomes  strong,  the  pulse  fuller,  slightly  quick,  and  the  cyanosis 
of  the  extremities  disappears;  the  skin  becomes  warm,  covered  with  perspira- 
tion, and  the  cheeks  grow  red.  The  body-weight  increases  markedly.  The 
patient  becomes  freer  in  movement,  shows  spontaneity,  helps  in  simple  house- 
hold work,  and  takes  part  in  games  of  cards.  His  voice  becomes  stronger, 
louder,  and  it  is  easier  for  him  to  express  his  thoughts. 

On  some  days,  especially  when  the  patient  has  been  too  much  occupied 
out  of  bed,  he  is  ag;ain  somewhat  lost  and  \azy.  but,  on  the  whole,  he  gains 
from  week  to  week  mentally  and  physically.  June  10th  he  was  discharged, 
completely  recovered;    Aveight  at  the  time  of  discharge,  63.5  kilograms. 

His  account  of  events  previous  to  his  illness  is  as  follows:  From  Christ- 
mas, 1880,  he  was  tired,  lost,  and  forgetful,  felt  Aveak  in  his  limbs,  and  now 
and  then  a  sense  of  oppression  in  the  chest.  Finally  he  became  absolutely 
dimib,  idiotic,  and  no  longer  knew  anj'thing  about  himself.  Of  what  hajipened 
thereafter  he  had  only  a  summary  memory.  No  history  of  melancholic  ele- 
ments, delusions,  and  liallucinations  can  be  obtained,  and  observation  never 
revealed  them.  From  Easter  on  he  felt  freer  in  his  head,  and  again  began  to 
think.  The  patient  deems  his  disease  to  be  due  to  overwork,  poor  nourish- 
ment, and  onanism;  but  there  Avas  also  a  neuropathic  constitution,  and  his 
rapid  growth  during  the  last  few  years  was  notable  (the  sleeves  of  a  coat 
bought  tAvo  years  ago  were  more  than  six  centimeters  too  short).  The 
recovery  was  permanent. 

(h)  Stupidity  Due  to  Psychic  Shock. 

This  clinico-etiologic  group  folloAvs  the  foregoing,  and  consti- 
tutes a  transition  to  the  next.  The  exciting  cause  is  an  affect,  usually 
fright;  the  pathogenic  element  is  probably  vasomotor  disturbance 
(vascular  spasm)  due  to  emotional  shock.  A  predisposition  is  always 
present,  and  still  more  important  than  in  cases  of  the  foregoing 
group.  When  the  predisposition  is  marked  (tainted,  usually  neuras- 
thenic or  otherwise  exhausted  brain,  hysteria,  etc.),  the  psychic  shock 
may  immediately  destroy  the  integrity  of  the  mental  functions. 

Analogous  functional,  but  limited,  disease-states  are  those  of 
aphasia  due  to  fright  and  the  hysteric  monoplegias. 

The  outbreak  of  the  disease  is  always  sudden.     It  begins  iiu- 


PSYCIIONEUROSES— PRIMARY  CUR-ABLE  STATES.  337 

mediately  with  stupor,  or  dcvoJops  out  of  a  pathologic  aftect  that  has 
lasted  hours  or  days,  or  out  of  anxious  confusion  with  or  without 
delusions  and  hallucinations.  There  are  slight  cases  of  simple  con- 
fusion or  mental  torpor,  and  severe  cases  of  profound  mental  cloud- 
iness going  ultimately  to  a  state  of  stupor.  The  latter  are  character- 
ized hy  contracted  pulse,  which  frequently  alternates  with  opposite 
conditions  of  vasomotor  paralysis;  and  then  there  may  he  violent 
congestion,  even  elevation  of  temperature  to  39°  C,  and  more  appre- 
hensive restlessness  with  vague  delusions  or  profound  stupor  as  the 
probable  expression  of  transudative  processes.  Slight  cases  usually 
pass  off  in  a  few  weeks.  Severe  cases,  and  these  are  always  accom- 
panied by  pronounced  vasomotor  implication  and  predominant  stupor, 
may  recover  within  a  few  months,  presenting  remissions  and  exacer- 
bations; or  these  latter  may  go  on  with  symptoms  of  persistent 
vasomotor  paralysis  to  apathetic  dementia. 

With  reference  to  cases  of  simple  stupidity  from  exhaustion,  it 
is  still  to  be  noted  from  a  diagnostic  standpoint  that  the  original 
affect  which  acted  as  a  cause  may  manifest  itself  now  and  again  in 
the  course  of  the  disease,  even  though  it  be  in  the  form  of  delirium. 

Case  15. 

E.,  aged  25,  overseer;  was  admitted  into  the  psychiatric  clinic  .June  15, 
1887.  The  parents  were  said  to  be  liealthy;  a  sister  epileptic  without  cause 
since  the  age  of  puberty.  The  patient  was  well  endowed,  industrious,  good, 
and  always  of  very  gentle  and  sensitive  character.  He  had  had  no  severe 
diseases.  Every  spring  he  was  accustomed  to  have  profuse  epistaxis.  This 
did  not  occur  in  1887.  For  some  months  the  patient  had  overworked  and 
had  had  many  troiibles.  On  the  evening  of  June  12th  he  had  a  violent  dispute. 
He  came  home  disturbed,  said  little,  stared  straight  before  him,  and  to  over- 
come his  depression  went  to  a  cafe,  drank  about  three  to  four  liters  of  wine, 
and  had  another  unpleasant  dispute.  The  night  of  the  13th  he  did  not  sleep, 
being  always  preoccupied  with  these  troubles. 

On  the  13th  he  went  to  work,  but  he  had  to  be  brought  home,  for  he  did 
nothing  but  look  straight  before  him.     He  was  pale  and  did  not  speak. 

The  night  of  the  14th  he  Avas  sleepless  and  wept  about  his  trouble.  On 
the  14th  he  lay  quiet  and  silent  in  bed.  The  night  of  the  15th  he  became 
apprehensive  and  asked  for  a  priest. 

Admitted  the  same  day,  he  was  pale,  without  fever ;  pulse  small,  con- 
tracted artery;  exhausted,  confused,  and  had  no, idea  of  time  and  place.  He 
thought  he  was  in  prison,  although  he  had  not  been  accused  of  anything.  To 
repeated  questions  he  gave  only  short  answers  in  a  low,  hesitating  voice.  His 
attitude  M^as  relaxed,  broken;  the  eyes  wide  open,  glance  fixed,  the  pupils 
wide;  reacted  lazily;  pulse,  72;  respiration  superficial  and  rapid.  The  patient 
of  medium  size,  reduced  in  general  condition;  examination  of  vegetative 
organs,  negative.  Cranial  circumference,  54  centimeters.  Rhombocephalic 
(right  diagonal  diameter,  12  centimeters;  left,  13  centimeters);  prominent 
parietal  eminences;    no  signs  of  rickets. 

22 


3J8  SrECTAL  PATIinT.OriY  ANP  TTlERArY  OF  INSANITY. 

Thereafter  the  patient  seemed  inhibited,  lost,  confused,  and  unconscious 
of  his  surroundings,  stoning  straight  before  him,  silent  and  devoid  of  all 
initiative.  He  liad  no  emotional  feeling,  except  that  he  was  occasionally  appre- 
hensive. At  first  sleep  was  wanting,  but  occurred  after  the  administration  of 
paraldehyde.  On  tlic  23d  the  patient  became  brigliter  mentally,  his  expression 
more  lively,  and  his  voice  stronger.  He  said  that  on  the  13th,  after  a  violent 
distress,  he  liad "become  completely  confused;  since  two  days  he  was  better  in 
his  head.  He  had  only  a  sunimary  recollection  of  tlic  time  of  liis  sickness, 
and  thought  he  liail  been  ci:i/,y  for  two  days.  Un  I  !ic  ."Ullli,  afUr  a  profuse 
bleeding  at  the  nose,  the  palicnl  liccamc  mentally  free,  and  his  expression  was 
in  accord  with  this.  He  said  that  in  a  state  of  apprehensive  confusion  he 
could  not  straighten  himself  out  nor  think  properly.  The  external  world 
seemed  changed  and  incomprclicnsil)le  to  him.  He  had  headache  and  vertigo. 
Tlie  patient  could  report  nothing  indicating  hallucinations.  Discharged  re- 
covered, July  10,  1887. 

(c)  Stltidity  Due  to  Mechanical  Shock. 

Followiiig  iiianii'estations  of  cerebral  concussion,  and  directly 
developing  out  of  them,  there  are  sometimes  conditions  of  profound 
mental  torpor  wliich  may  go  to  the  degree  of  absohite  absence  of  con- 
sciousness of  the  personalit}',  called  psychoses  due  to  traumatic 
concussion,  and  which  may  be  regarded  as  a  protracted  fortu  of 
commotion  of  the  psychic  organ,  after  the  functions  of  the  sub- 
cortical and  automatic  centers  have  been  restored.  These  condi- 
tions of  the  cortex  probably  depend  upon  disturbance  of  molecular 
condition  resulting  from  trauma,  functionally  they  may  be  regarded 
as  inhibitory  processes  affecting  the  psychic  organ.  Just  as,  according 
to  modern  investigation,  cerebral  concussion  represents  an  inhibitory 
cerebral  neurosis.     Similar  conditions  may  arise  from  strangulation. 

Stupidity  in  these  tramnatic  cases  seems  to  be  the  cumuUitive 
expression  of  inhibitory  processes  in  the  varioTis  territories  and  cen- 
ters of  the  cortex ;  at  least  in  classic  cases  variation  of  the  intensity 
of  the  functional  loss  in  various  centers,  and  variation  in  the  restora- 
tion of  the  function  of  affected  territories,  are  observed.  The  prog- 
nosis seems  favorable. 

In  five  cases  of  personal  observation  recovery  occurred.  In  two 
cases  there  was  termination  in  mental  weakness.  Careful  manage- 
ment and  watching  during  convalescence  seem  to  be  the  most  impor- 
tant points  in  treatment.- 

Case  16. 

On  June  10,  1887,  H.,  farm-laborer,  aged  29,  of  Steiermark,  was  admitted 
from  the  surgical  ward  of  the  hospital  at  Gratz,  with  the  note  that  "He 
does  not  seem  to  understand  questions  nor  to  comprehend;  says  his  name 
is  Franz  Mehlmauer;  has  no  fever;  pulse,  64;  no  vegetative  anomalies." 
The  left  ilieek  is  black  and  blue,  the  right  ear  full  of  blood-clots,  but  the  ear- 


rSYCHONEUROSES— rRIMARY  CURABLE  STA'|-KS.  330 

drum  is  uninjuied.  On  walking  the  patient  staggers  like  a  drunken  man,  and 
he  sits  in  stupid  quiet.     Temperature,  36.8°  to  37.4°  C. 

The  night  of  the  14th  he  got  up  and  ran  out  in  his  night-clothes  in  the 
court,  wliere  he  was  found  covered  with  fllth,  and  was  transferred  to  the 
psychiatric  clinic.  On  the  morning  of  the  15th  I  found  him  stupid.  He  slept 
much,  yawned  frequently,  and  presented  a  sleepy,  stupid  expression.  He  hears 
and  sees,  but  juisunderstands  impressions  made  on  him.  He  answers  questions 
incomprehensibly,  takes  the  food  offered  him,  gets  out  of  bed  staggering  to 
satisfy  his  needs,  but  is  quite  confused,  and  cannot  find  his  way  back  to  Ijed. 
Skull  normal,  without  traces  of  injury  and  not  sensitive  to  percussion;  no 
congestion,  no  symptoms  of  irritation,  and  no  vomiting;  temperature  011  tlu; 
morning  of  the  15th,  38.4°  C;  evening,  38.2°  C;  on  the  IGth,  32.4°  C,  and 
thereafter  normal.  Pain-sense  normal;  extreme  movements  of  aversion  to 
being  touched,  though  badly  carried  out.  The  patellar  reflex  is  wanting; 
pupils  of  medium  size,  equal,  and  reacting  normally. 

Patient  sleeps  almost  constantly  on  the  IGth,  and  has  to  be  forced  to  do 
everything.  Want  of  all  spontaneity,  but  his  notions  of  movement  are  qiiite 
intact.  The  patient  gives  no  attention  to  the  external  world.  When  a  needle 
is  brought  near  his  eye  he  makes  no  movement  of  the  lid.  ^\'hen  the  eye  is 
touched,  the  lid-refiex  occurs.  On  the  17th  the  patient  is  somewhat  freer  and 
shows  indications  of  attention  and  spontaneity;  gait  to-day  surer.  Patient 
begins  to  speak.  He  has  ataxic  aphasia.  A  silver  gulden  he  calls  "josel." 
He  understands  a  question  about  his  feelings.  "I  do  not  feel  so  A'ery  bad; 
I  fell  three  years  ago."  He  reaches  after  objects  with  interest,  but  does  not 
know  their  significance,  and  is  word-deaf  and  word-blind.  The  patellar  reflex, 
absent  until  now  as  an  accompaniment  of  the  general  inhibitor}'  state  of  the 
brain,  is  prompt,  remains  the  following  days  somewhat  increased,  and  then 
becomes  normal. 

On  the  21st  otorrhea  of  the  right  ear;  the  optic  and  acoustic  centers 
resume  their  functions.     Patient  is  still  aphasic. 

It  is  learned  to-day  from  legal  documents  that  the  patient  had  received 
a  blow  on  the  head  given  by  one  of  his  companions  with  a  stick  of  wood ;  that 
he  fell  immediately  unconconscious,  and  bled  from  the  right  ear.  Later  he 
vomited  food  and  bloody  mucus.  On  the  left  temple  there  was  marked  effu- 
sion of  blood.  The  physician  summoned  found  the  patient  in  "coma":  pulse, 
80  to  84;  temperature  normal;  the  corner  of  the  mouth  drawn  to  the  left. 
On  the  8th  of  June  the  patient  was  examined  by  the  police  physician.  He 
found  him  conscious,  hut  capable  only  of  inarticulate  sounds. 

June  24th  the  patient  became  much  brighter.  He  recognized  the  hour, 
became  freer  in  speech,  and  seemed  less  aphasic,  but  he  was  still  confused.  On 
the  26th  he  thought  he  Avas  at  home,  and  in  his  reckoning  of  time  he  had  not 
gone  beyond  the  4th  or  5th  of  June.  He  knew  nothing  of  the  blow  on  his 
head.  He  understood  all  questions  and  the  meaning  of  all  objects  shown  him, 
but  he  could  not  in  many  instances  call  them  by  name  (amnesic  aphasia).  He 
coiüd  remember  the  events  of  the  day  before — examination  in  clinic.  On  the 
28th  he  is  freer,  but  liis  thought  is  still  difficult  and  slow.  Aphasia  disa2>pears. 
Now,  as  before,  no  memory  of  the  time  of  the  accident  and  of  his  sickness. 

July  2d  his  power  of  comprehension  of  time  and  place  returns.  The 
memory  of  the  blow  and  the  circumstances  returns  in  all  details.  He  feels 
perfectly  well. 


^,10  SPKriAT-  PATllOl.tKlY   AM)  'lllKi;  \l'^    (U'   INSAMIY. 

July  Itlh  tlic  iialicnt  says,  in  s|)oakin<i  of  liis  niemoiy  of  past  ovoiits, 
that  imiuoilialoly  after  the  blow  he  hocainc  unconscious.  It  was  only  on  the 
10th,  after  bein«;  brought  to  Urat/.  tliat  he  came  to  himself;  that  he  noticed 
he  was  going  through  a  town,  but  he  did  not  recognize  his  sister  and  a  com- 
panion who  accompanied  him.  After  tiiat,  ho  lost  liis  senses  again.  From 
that  time  until  June  23d  he  had  no  memory  of  any  tiling  except  that  he 
was  constantly  dizzy,  sleepy,  and  had  headache  when  he  lay  on  liis  right  side. 

June  22d  he  had  suddenly  noticed  that  food  was  put  before  him  aniLthat 
he  was  in  bed.  On  the  2:5d  and  24th  he  liad  asked  of  ilmse  about  him  where 
he  was  and  what  had  happened  to  him.  (Jradually  lie  had  been  able  to  recall 
all  that  had  taken  place.  Careful  observation  and  examination  thereafter  show 
no  mental,  and.  in  general,  no  cerebral  disturbance;  so  that  the  patient  was 
discharged  recovered  on  Julv  20th. 


CHAPTER  IV. 
Primary  Hallucinatory  Insanity. 

The  states  of  hallucinatory  insanity  now  to  be  described  rest 
essentially  n2)on  the  same  foundation  as  the  disease-picture  of  stupid- 
ity described,  in  Chapter  III :  i.e.,  upon  functional  exhaustion,  upon 
asthenia  of  the  nervous  system  (asthenic  psj'choneurosis).  The  dif- 
ference is  that  the  cerebral  exhaustion  does  not  reach  the  degree  of 
complete  arrest  of  mental  processes,  except  episodically ;  and  that  in 
the  exhausted  brain  irritative  processes  go  on  essentially  in  the 
sensorium,  though  occasionally  also  in  the  psychomotor  areas  of  the 
cortex.  Under  the  term  hallucinatory  insanity  employed  by  Meynert 
the  following  description  comprehends  all  the  psychoneuroses  based 
upon  functional  exhaustion  and  Aveakness  in  the  higher  psychic 
activities  of  attention  and  judgment,  the  principal  symptoms  of  which 
are  hallucinations,  and  delusions  arising,  for  the  most  part,  out  of 
them,  accompanied  by  consequent  anomalies  of  feeling  and  action. 

The  conditions  necessary  for  the  origin  of  this  delirious  disease- 
picture  are  essentially  the  same^  as  those  of  febrile  and  inanition 
delirium,  especially  disturbances  in  the  nutrition  of  the  cortex;  and 
the  fact  is  that  such  conditions  of  hallucinatory  insanity  not  infre- 
quently arise  out  of  febrile  diseases  and  are  postfebrile  psychoses. 
The  transitions  from  the  usually  temporary  delirium  which  occurs 
as  an  accompaniment  of  febrile  processes  (comp,  page  ITG)  to  the 
asthenic  postfebrile  protracted  psychoses  are,  at  any  rate,  easy. 

The  more  the  disease  is  separated  from  or  outlasts  the  causal 
somatic  malady  or  arises  in  the  course  of  convalescence  from  a 
delirious  state,  the  clearer  it  appears  as  an  independent,  peculiar 
process  in  course  and  symptoms. 


PSYCIIONEUROSES— PRIMAKY  CURABLE  STA ^J' ES.  341 

The  reason  that  such  a  disoasc-picturc  should  tako  on  a  pro- 
tracted and  independent  form  probably  lies  in  a  special  predisposition 
of  the  brain  subjected  to  a  general  disturbance  of  its  nutrition  (fever, 
inanition). 

These  predispositions  are  alike  in  this:  the  brain  subjected  to 
the  disease  process  -is  unusually  easily  exhausted  and  lacking  in  re- 
sistive power.  This  irritable  weakness  may  be  founded  on  a  neuro- 
pathic and  frequently  hereditary  constitution,  not  infrequently  ac- 
companied by  tangible  signs  of  rachitic  hydrocephaly;  it  may  be 
acquired  as  a  result  of  mental  and  physical  strain;  it  may  be  due 
to  alcoholic  or  sexual  excesses,  or  to  chronic  diseases  which  interfere 
with  general  nutrition  (gastric  .diseases,  anemia,  suppuration),  fre- 
quent childbearing,  lactation,  etc. 

It  is  clear  that,  upon  such  a  foundation,  exciting  causes,  like 
childbed,  hemorrhages,  fever,  and  other  acute  and  grave  aifections  of 
the  organism,  induce  niitritive  disturbances  in  the  cortex  that  do  not 
disappear  immediately,  but  rather  cause  profound  and  lasting  dis- 
turbances of  the  psychic  functions. 

A  great  part  of  the  so-called  postfebrile  psychoses,  and  in  gen- 
eral those  that  develop  after  acute  exhausting  diseases,  belong  in  this 
category.  Especially  to  be  mentioned  are  cases  of  hallucinatory  in- 
sanity developing  out  of  malarial  cachexia  lasting  months  or  even 
years,  and  cases  of  hallucinatory  delirium  with  confusion  arising 
during  an  attack  of  acute  articular  rheumatism  lasting  three  to  six 
weeks,  and  continuing  thereafter.  In  this  class  also  belong  states  of 
postfebrile  insanity  after  pneumonia,  which  is  especially  prone  to 
develop  in  drinkers ;  and  finally  the  numerous  psychoses  that  develop 
during  convalescence  from  typhoid  fever  {comip.  "Etiology^').  Not 
infrequently  states  of  inanition  during  imprisonment  are  of  this 
nature  (prison  insanity).  Too,  a  large  number  of  puerperal  psy- 
choses, for  the  most  part  regarded  as  mania,  belong  here.  (Halluci- 
natory insanity — Fürstner.) 

From  a  purely  symptomatic  standpoint,  the  specific  alcoholic 
delirium  of  persecution  should  be  placed  in  this  category  {vide 
"  Chronic  Alcoholism,"  insanity  of  persecution),  and  the  protracted 
delirium  of  epileptics  and  hysterics  as  well,  especially  when  it  occurs 
as  an  equivalent. 

Melancholia  and  mania  developing  upon  the  foundation  of  an 
exhausted  brain,  and  the  episodic  states  of  hallucinatory  confusion 
in  paranoia,  which  are  not  very  infreqiient,  belong  strictly  in  this 
class.  At  the  height  of  these  states  induced  by  sleeplessness,  refusal 
of  food,  and   extreme  expenditure  of  vital  force  with  insufficient 


2i2  SIM.t  lAL  rATITOLOGY  AND  TIlKl^ATY  OF  IXSAXTTY. 

restitution,  we  observe  independent  conditions  characterized  by  hal- 
Inoinations  and  doliriuni  of  inanition,  which  for  the  time  being  push 
aside  tlie  picture  of  melancholia,  mania,  or  paranoia;  and  it  is  only 
with  improvement  of  the  general  condition  that  the  original  form  of 
disease  again  makes  its  appearance. 

The  disease-conditions  treated  here  as  primary  hallucinatory  in- 
sanity correspond,  for  the  most  part,  with  the  acute  primary  insanity 
of  other  authors  ("Westphal),  hallucinatory  confusion,  hallucinatory 
mania  (Mendel),  and  delusional  stupor  (Xewington). 

The  stage  of  incubation  of  primary  hallucinatory  insanity  is 
short,  seldom  longer  than  a  few  hours  or  days;  but,  of  course,  symp- 
toms of  nervous  exhaustion  and  irr;table  weakness  have  often  pre- 
ceded the  outbreak  for  a  long  time. 

Almost  constant  symptoms  of  the  developing  disease-picture  are 
sleeplessness,  or  unrefreshing  sleep  with  anxious  dreams  and  fright- 
ful awakenings;  nervous  excitement,  irritability,  anxiety,  headache, 
vertigo,  depression,  and  inhibition  and  confusion  of  ideas,  with  some 
desultory  hallucinations. 

The  progress  to  the  height  of  the  disease  is  reached  quickly, 
with  multiplication  of  hallucinations.  The  principal  symptoms  at 
the  height  of  the  malady  are,  at  any  rate,  errors  of  the  senses,  both 
illusions  and  hallucinations;  in  acute  cases  especially  they  are  visual, 
then,  in  order  of  frequency,  auditory,  and  finally  sensory,  olfac- 
tor}'',  and  gustator3^  Not  infrequently  they  occur  in  all  the  senses, 
and  are  so  numerous  that  there  is  quickly  a  decided  clouding  of  con- 
sciousness. The  patients  are  confused  and  have  no  idea  of  their 
situation. 

In  acute  stormy  cases  there  is  a  kaleidoscopic  variation  of  hal- 
lucinatory and  illusional  situations.  In  cases  that  are  more  chronic 
in  their  course  the  errors  of  the  senses  are  not  so  numerous,  and 
more  episodic;  so  that  there  may  be  delusions  of  some  duration  with 
logical  connection. 

The  content  of  the  delusions  is  extremely  varied  and  changeable. 
There  may  be  delusions  of  persecution,  poisoning,  sin,  hypochondria, 
eroticism,  religion,  and  grandeur,  in  content  like  those  of  the  para- 
noiac, but  always  without  any  system.  These  delusions  almost 
exclusively  develop  out  of  errors  of  the  senses,  or  they  may  be  pri- 
mordial. It  is  only  occasionally  that  they  represent  the  allegoric 
interpretation  of  sensations. 

The  patient  lives  in  delirious  situations,  anxious,  troubled,  irri- 
tated, or  astonished,  as  a  result  of  the  moinentary  content  of  his 
troubled  consciousness.    He  thinks  himself  for  a  moment  possessed, 


PSYCHONEUROSES— PRIMARY  CUP.ABLE  STATES.  o.\o 

a  saint,  God,  the  emperor,  etc.,  and  for  a  time  develops  a  logical  idea 
out  of  the  errors  of  the  senses  and  delusions;  but  he  never  goes  so 
far  as  to  create  a  formal  system  of  delusions,  or  a  lasting  alteration 
of  the  personality  in  a  delusional  sense. 

In  severe  cases,  and  in  an  episodically  profound  state  of  ex- 
haustion, delusions  of  grandeur  may  predominate.  In  other  cases 
the  delirium  is  concerned  almost  exclusively  with  frightful  situations. 
A  dilferentiation  of  disease-pictures  according  to  the  content  of  de- 
lusions, possible  in  paranoia,  seems  here  unnecessary  and  inappropri- 
ate, if  not  impossible. 

A  further  important  clinical  fact  is  the  disturbance  of  conscious- 
ness of  the  patient:  his  lack  of  orientation  with  reference  to  place 
and  time.  This  explains  the  confusion  of  the  speech  and  acts  of  such 
patients. 

This  confusion  is  essentially  to  be  referred  to  the  two  funda- 
mental series  of  symptoms  of  the  disease-picture:  the  functional 
weakness  of  the  intellectual  organ;  the  overfilling  of  consciousness 
with  errors  of  the  senses. 

The  first  disturbance  seems  especially  to  affect  apperception  and 
the  processes  of  judgment.  The  power  of  apperception  of  the  ex- 
hausted brain  is  in  part  simply  enfeebled  temporarily,  even  to  the 
extent  of  true  mental  blindness  and  deafness;  and  in  part  this  fac- 
ulty is  interfered  with  by  the  patient's  loss  of  attention,  due  to  the 
great  number  and  extremely  lively  and  constantly  changing  illusions 
and  hallucinations. 

Since  the  perception  of  sense-impressions  from  the  external 
world  is  not  impossible,  but  largely  merely  distorted  in  consciousness, 
and  since  purely  subjective  sensations  occur  with  those  that  are 
objective  and  partly  correct,  confusion  and  lack  of  orientation  must 
necessarily  arise,  which,  for  this  form  of  mental  disease,  are  charac- 
teristic. 

Along  with  the  disturbance  of  apperception,  however,  there  are 
others  still  more  important  in  their  effect  upon  the  course  of  ideas : 
the  constant  penetration  of  delusions  and  errors  of  the  senses  into  the 
developing  course  of  thought,  which  in  itself  ma}^  be  logical;  as  a  re- 
sult of  which  the  thread  of  thought  is  constantly  interrupted,  and 
new  and  disparate  combinations  of  thought  are  created.  Too,  there 
is  the  tendency  of  the  weakened  mechanism  of  association  to  connect 
ideas  mainly  in  accordance  with  simple  superficial  shnilarity  of  sound, 
thus  giving  rise  to  the  most  strange  thoughts.  In  addition  to  all  this, 
there  is  still  the  grave  enf  eeblement  of  the  power  of  judgment,  which 
is  an  expression  of  the  functional  weakness  of  the  brain. 


3-li  SPECIAL  PATHOLOGY  AND  TIIKIIAI'Y  OF  IXSAXITY. 

This  explains  also  the  important  i'act  that  the  enormous  amount 
of  hallneinatorv  and  delusional  material  undergoes  no  logical  valua- 
tion or  combination  into  a  systematic  delusional  idea. 

HoAvever,  the  disturbance  of  consciousness, in  hallueiuatory  con- 
fusion is' not  so  deep  as  that  which  occurs  in  stuporous  patients; 
and  thus  is  explained  the  fact  that,  aside  from  episodes  of  actual 
stupor,  the  patient  jjossesses  comijaratively  correct  recollection  of 
Ihe  delirious  events  of  the  disease;  indeed,  during  periods  of  re- 
mission, and  with  a  return  of  correct  apperception  and  temporary 
power  to  judge  of  his  disease,  the  patient  says  that  he  is  crazy,  subject 
to  somnambulism,  talks  of  going  insane,  of  the  asylum,  or  of  being 
bewitched,  possessed,  or  h3-pnotized. 

The  very  lively  emotional  feelings  and  affects  whicli  oL'ten  occur 
in  the  course  of  the  disease-picture  are  reactions  to  the  primary 
errors  of  the  senses  and  delirium.  In  accordance  with  the  rapid 
change  in  the  content  of  these,  they  arc  accompanied  only  by 
very  temporary  and  changeable  states  of  feeling.  Since  fright- 
ful hallucinations  and  persecutory  ideas  usually  predominate,  there 
is  most  frequently  anxiety  and  depression.  Whether  feelings  of  ap- 
prehension occur  spontaneously  in  these  patients  »is  scarcely  to  be 
determined.  jSTot  infrequently,  based  upon  the  frightful  subjective 
processes  and  hostile  apperception,  there  is  great  irritability,  dan- 
gerous violence  toward  others,  even  attempts  at  suicide,  and  desperate 
efforts  to  escape.  Frequently  there  is  refusal  of  food  in  connection 
with  ideas  of  poisoning  and  errors  of  the  senses.  Just  like  the  emo- 
tional reaction,  the  acts  of  these  patients  are  purel}^  reactive  phe- 
nomena. The  acts  seem  quite  as  abrupt  and  disconnected  as  the 
delirious  ideas  which  cau.se  them.  Owing  to  the  confusion  of  the 
patients,  they  are,  like  those  of  delirium  in  general,  largely  withiut 
purpose  and  distorted.  The  course  of  the  disease  is  characterized  by 
remissions  and  exacerbations.  The  former  occur  often  quite  unex- 
pectedl}',  and  may  be  characterized  by  relative  lucidity.  The  latter 
are  often  related  to  new  enfeebling  causes,  such  as  continued  sleep- 
lessness and  refusal  of  food.  Almost  without  exception,  in  women  the 
menstrual  processes  lead  to  such  a  result,  even  when  the  menses  do 
not  occur  and  the  loss  of  blood  is  not  a  weakening  causal  factor. 

During  periods  of  diminution  of  the  symptoms  «f  irritation 
(errors  of  the  senses,  delirium)  there  is  the  clinical  picture  of  cerebral 
exhaustion,  with  weeping  or  irritability  as  emotional  anomalies. 

As  an  episodic  condition  in  severe  cases  there  may  be  stupor 
lasting  some  weeks,  or  maniacal  states  lasting  from  a  few  hours  to 
a  day.     The  latter  conditions  may  resemble  the  picture  of  severe 


PSYCnONEUROSl<:S— riÜMAr.Y  CllWAVAJ':  SI'A'I'KS.  34:0 

mania  in  the  form  of  cerebral  irritation,  Init  there  is  no  pronounced 
flight  of  ideas,  and  they  may  be  regarded  as  states  of  psychomotor 
cerebral  irritation,  since  they  are  usually  accompanied  by  verbigera- 
tion, automatic  cramp-like  movements,  whistling,  grimacing,  etc. 
Occasionally  under  such  circumstances  there  may  be  tonic  ajid  (donic 
convulsions,  cataleptiform  and  ecstatic  states  (catatonia). 

The  more  or  less  pronounced  affection  of  the  general  organism 
in  this  state  manifests  itself  in  the  profound  reduction  of  general 
nutrition,  the  subnormal  temperature,  and  the  reduced  turgor  vitalis; 
in  the  weak,  easily  compressible  puJse,  and  the  cessation  of  the 
menses  at  the  lieight  of  the  disease.  In  a  case  observed  by  the 
author,  in  a  woman,  the  weight  on  admission  was  43  kilograms  as 
compared  with  61.3  kilograms  when  discharged.  ISTot  infrequently 
there  is  inanition,  with  tremor  of  the  tongue  and  extremities.  At  the 
height  of  the  disease  sleep  is  almost  always  disturbed. 

The  duration  of  the  disease  is,  on  an  average,  several  months, 
though  it  is  not  rare  to  see  abortive  cases  ending  in  a  few  days  or 
weeks.  On  the  other  hand,  some  cases  last  a  year  or  more.  The 
cases  of  shortest  duration  are,  in  general,  those  of  menstrual  or  post- 
febrile origin.  The  puerperal  cases  have  a  duration  between  the 
two  extremes. 

The  possible  terminations  of  acute  hallucinatory  insanity  are 
recovery,  transition  to  incurable  mental  weakness,  and  death.  The 
prognosis  is  quite  favorable.  Eecovery  resulted  in  over  70  per  cent, 
of  my  cases. 

As  a  transitional  stage  to  recovery  there  are  delirious  periods 
of  cerebral  irritation,  outlasting  the  states  of  exhaustion,  usually 
accompanied  by  irritable  emotional  states ;  in  severe  cases  a  state  of 
stuporous  exhaustion  may  form  the  transition  to  recovery.  Meynert 
has  seen  the  disease  pass  to  recovery  through  states  of  a  maniacal 
nature.  He  assumes  that  the  mania  due  to  functional  hyperemia 
with  increase  in  rich  arterial  blood  acts  as  a  means  to  restore  the 
exhausted  brain  that  has  been  attacked  by  hallucinatory  confusion 
(anemia) . 

Termination  in  incurable  mental  weakness  depends  upon  the  fact 
that  the  exhausted  brain  is  no  longer  able  to  re-establish  its  normal 
nutritive  condition,  and  retrograde  changes  that  finally  end  in  atrophy 
of  the  cortex  take  place.  As  a  result  of  this  there  are  lasting  deficien- 
cies in  psychic  activities,  and  the  brain  becomes  progressively  less 
capable  of  correct  apperception  and  the  formation  of  correct  proc- 
esses of  judgment,  in  spite  of  the  fact  that  delirium  and  errors  of  the 
senses  become  less  frequent  and  fade. 


r,\G  Sl'EriAL  PATHol.ocY   .\\1>  'rilKHAI'V  oK   IXSANl'l'V. 

Under  such  circunistain'cs  the  emolioiis  and  acts  become  pro- 
gressivel}^  more  feeble  and  fragiuentarv;  thus  gi'adually  a  state  of 
lasting  general  confusion  results. 

A  transition  to  systematic  paranoia  I  have  never  yet  observed. 
Theoretically  it  is  not  conceivable,  for,  at  the  height  of  the  disease, 
the  exhausted  brain  never  beconies  sulFiciently  restored  to  form  a 
logical  valuatioji  and  assoc-iaiion  of  delusions;  but,  Avbou  the  course 
of  the  disease  is  favorable,  the  false  ideas  are  quickly  corrected,  and 
errors  of  the  senses  retreat  into  the  background.  To  regard  the 
disease-picture  as  an  acute  paranoia  is  therefore  untenable.  In  sucli. 
cases  the  process  is — genetically,  clinically,  and  from  the  standpoint 
of  prognosis — quite  different,  and  therefore  requires  a  special  desig- 
nation . 

Fatal  termination  is  possible  as  a  result  of  progressive  exhaustion 
and  a  final  state  of  inanition  like  that  of  acute  delirium.  It  may  be 
pneumonia,  or  especially  pulmonary  phthisis  favored  by  reduced 
nutrition  and  insufficient  respiration,  that  finally  overcomes  the 
exhausted  organism. 

States  of  acute  hallucinatory  insanity  may  present  differential 
diagnostic  difficulties  in  respect  to  mania,  melancholia,  and  the  acute 
delirious  episodes  of  paranoia. 

With  regard  to  mania  it  may  be  said  that  upon  the  foimdation 
of  cerebral  exhaustion  there  may  be  disease-pictures  which  resemble 
very  closely  those  of  hallucinatory  insanity,  since  there  may  be  here 
numerous  errors  of  the  senses  and  inanition  delirium  which  terapo- 
raril}'-  predominate.  On  the  other  hand,  in  acute  hallucinatory 
insanity,  as  a  reaction  to  the  delirium,  there  is  often  very  lively 
motor  unrest,  complicated  also  by  manifestations  of  psychomotor 
irritation,  which  easily  simulates  maniacal  states,  and  which  also 
occurs  episodically  as  a  complication  (mania  menstrualis),  and  finally 
as  a  transitional  stage  to  recovery.  In  relation  to  the  first  condition 
it  should  be  remembered  that  symptoms  of  genuine  motor  impulse 
and  actual  flight  of  ideas  are  foreign  to  the  picture  of  acute  hallu- 
cinatory insanity;  that  the  anomalies  of  emotion  and  motor  activity 
are  reactive  manifestations,  and  that  motor  activity  appears  upon 
the  scene  not  so  much  as  a  purely  automatic  motor  impulse  as  a 
distinct  act  dependent  upon  delirium  and  errors  of  the  senses. 

The  episodic  or  final  mania  is  recognized  as  an  episode  by  a 
careful  consideration  of  the  general  course  of  the  case.  Acute  hal- 
lucinatory insanity  may  also  appear  to  be  active  melancholia:  the 
anxiety  due  to  frightful  delirium  and  errors  of  the  senses  is  mistaken 
for  a  symptom  of  active  melancholia.    In  this  case,  also,  consideration 


PSYCnONKlTROSKS— PHIMARY  f'UüAI'.LK  S'I'ATKS.  317 

of  the  course,  and  the  fact  that  agitated  melancholia  is  only  an  episodic 
■exacerbation  of  a  (lisease-pictnre  due  to  inhibition  and  yrrimary  psy- 
chic pain,  will  permit  the  dilferentiation.  From  paranoia,  acute  hal- 
lucinatory insanity  is  differentiated  by  the  important  characteristic 
that  in  hallucinatory  insanity,  even  when  it  lasts  a  long  time,  there 
is  no  systematization  or  logical  combination  of  the  delusional  ideas 
into  a  formal  delusional  structure.  It  must  be  admitted  that  now 
and  then,  especially  during  periods  of  remission,  and  in  chronic 
cases  of  hallucinatory  insanity,  the  patients  draw  some  logical  con- 
clusions based  upon  delirium  and  errors  of  the  senses,  and  that  there 
are  series  of  delirious  ideas  which  are  brought  into  relation;  but  this 
is  only  accidental,  episodic,  and  not  regular  and  lasting  as  in  paranoia. 
Method  is  wanting  in  acute  hallucinatory  insanity.  The  delusions 
remain  disconnected  masses  of  ideas  and  form  a  pure  hallucinatory 
delirium;  with  that  there  are  also  the  profound  disturbance  of  con- 
sciousness and  the  formal  process  of  .bought,  and  also  sudden 
change  of  delusions.  The  manner  of  development  is  also  decisive: 
acute  hallucinatory  insanity  develops  quickly,  while  in  paranoia  the 
stage  of  incubation  of  suspicions  and  premonitions  lasts  months  or 
years.  It  is  only  the  conditions  of  hallucinatory  delirious  confusion, 
which  not  infrequently  occur  in  the  course  of  paranoia,  that  j)resent 
difficulties  and  allow  the  condition  to  be  mistaken  for  the  disease- 
picture  of  acute  hallucinatory  insanity.  Knowledge  and  appreciation 
of  the  general  course  of  the  disease,  under  such  circumstances,  will 
make  the  case  clear. 

The  most  important  therapeutic  indications  in  acute  halluci- 
natory insanity  arise  out  of  the  asthenic  foundation  of  the  disease,  as 
is  clearly  shown  by  the  etiology  and  the  clinical  picture  itself.  It  is 
only  when  these  indications  are  fulfilled  that  the  diagnosis  is  favor- 
able. He  who  treats  his  patient  by  bloodletting,  purgation,  insuffi- 
cient food,  leaves  him  to  himself,  or  employs  counter-irritating 
ointments  and  the  like,  will  have  very  iew  favorable  results. 

Prophylactically,  in  considering  and  overcoming  asthenic  condi- 
tions during  febrile  diseases  and  the  puerperium  much  may  be  done. 
When  the  disease  has  manifested  itself,  the  most  important  thing  is 
good  nursing  and  nourishment.  The  patients  must  be  kept  in  bed, 
and  supplied  with  fresh  air  and  abundant  nourishment.  Meat,  milk, 
eggs,  and  wine  are  demanded  by  the  causal  and  symptomatic  indica- 
tions. In  a  severe  case  complicated  by  the  taking  of  insufficient  food 
I  have  found  Leube's  enemas  of  meat  and  pancreas  of  decided  value. 
Albuminuria  and  menstrual  hemorrhage  are  to  be  considered  and 
treated.     Sleeplessness,  which  is  often  obstinate  and  exhausting,  is 


348  SPECIAL  rAlllL)J.(HiY  AND    11  i  KKAI'V   OF   INSAMTY. 

liest  overc'oiiu'  In-  \)vvy.  \\iiu\  alcoliolics.  and  occasional  closes  of 
chloral;  and,  when  nutrition  is  better,  with  lukcwann  hat  lis.  When 
there  are  slates  of  ])rotound  inanition,  opiates,  best  in  connei-tion 
with  quinine,  which  also  acts  as  a  tonic  for  the  brain,  and  in  ^urcat 
necessity  camphor  (also  subcutaneously)  in  connection  with  opium, 
may  be  useful  to  overcome  cxcilcment  and  sleeplessness. 

Cask  17. — Postfebi'ilc  ac-ntc  liallm-inalory  insanity. 

M.,  aged  37,  single,  sluiciuakor.  of  healthy  family:  nut  a  iliiiikt'r,  Init  he 
has  always  been  weak;  his  skull  is  rac-hitic  and  hydrocephalic  (circninference, 
59  centimeters).  He  has  passed  through  a  febrile  disease  without  delirium  in 
the  last  five  weeks,  probably  typhoid.  Discharged  from  the  hospital  a  few 
days  ago,  and  rotm-ning  to  work  on  March  12,  1887,  he  became  confused, 
delirious,  and  ran  mit  in  the  street,  where  he  stared  tixedly  l)pf()re  him,  and  to 
questions  said  tliat  he  was  in  eternity.  Taken  by  the  police,  he  became 
anxious  and  expressed  fear  of  punishment  because  he  had  led  a  bad  life  of 
immorality.  When  received  at  the  clinic  on  March  14,  1887,  the  patient  was 
delirious,  confused,  and  wanting  in  orientation.  He  took  the  physician  for  the 
I'rophet  Elias,  and  on  his  knees  begged  him  to  save  him  from  thunder  and 
lightning,  as  he  was  an  honorable  man.  Then  the  patient  passed  into  a  state 
of  astonished  staring,  and  it  was  necessary  to  speak  to  him  repeatedly  before 
he  understood.  He  related  that  the  day  before  the  Virgin  Mary  appeared  to 
him.  He  had  vowed  to  become  a  martyr,  for  the  priest  had  told  him  at  con- 
fession that  he  shoxüd  not  live  with  women,  and  thus  would  attain  Heaven. 
The  patient  prays  and  kneels  frequently,  is  quite  ecstatic,  and  looks  at  the 
ceiling.  He  is  entirely  absorbed  in  errors  of  the  senses,  and  sleeps  little.  It  is 
learned  that  the  A'irgin  Mary  appears  to  him  constantly.  She  tells  him  that 
her  Son  had  been  tortured.  The  patient  takes  colored  spots  on  the  wall  of 
his  cell  for  the  place  where  Christ  was  murdered.  Christ  also  appears  to  him 
and  sings  him  heavenly  songs  of  martyrdom. 

The  patient  is  often  in  ecstasy.  At  times  he  appears  to  be  apprehensive. 
As  a  motive  it  is  learned  how  some  one  appeared  to  him  and  demanded  his 
sold,  because  otherwise  he  would  not  go  to  Heaven.  The  patient  had  to  sign 
and  then  blow  on  the  paper. 

He  then  went  to  Heaven  and  asked  God  to  give  him  back  his  soul,  which 
was  done.  Then  he  felt  relieved  and  happy  again.  On  the  IGth  the  patient 
was  used  for  a  clinical  demonstration.  He  thought  he  was  in  church  or  before 
the  court.  He  took  the  students  for  Apostles,  and  the  professor  for  God,  and 
that  he  was  not  worthy  enough  to  sit  near  him,  asking  God  to  save  him  from 
the  punishment  of  imprisonment.  With  good  nights  (paraldehyde)  and  good 
food  the  patient's  niind  rapidly  cleared  up,  and  he  passed  on  to  convalescence. 
He  had  perfect  memory  of  all  the  events  of  his  disease,  said  that  everything 
was  imagination,  and  that  the  cause  of  his  mental  disease  was  that  after  his 
fever  he  returned  to  Avork  too  weak  and  too  early.  Discharged  recovered, 
April  14,  1887. 

Case  18. — Acute  hallucinatory  insanity. 

D.,  aged  34,  cabinetmaker,  on  May  7,  1881,  became  confused  and  was 
brought  to  the  clinic.     Father  died  of  cerebral  paralysis.     As  a  chdd  the  pa- 


PSYCHONEUROSES-  TMM.MAÜV  (TRAIiLK  ST.\TKS.  ;;];) 

lient  was  weak  and  sickh',  but  well  endowed,  of  gay  disposition,  and  nut 
bigoted.  He  married  at  the  age  of  24,  liad  five  children,  all  of  whom  died,  Ihe 
last  of  convulsions  on  January  17,  1881.  The  latter  was  his  favorite.  At  his 
death  he  had  a  cataleptic  attack,  and  remained  several  minutes  pale,  staring 
before  him.  Cold  applications  brought  him  to  himself.  Since  this  time  he  has 
been  depressed  and  sorrowing  over  the  loss  of  his  child,  and  often  he  has  felt 
boring  pain  in  his  head  when  thinking  of  him.  The  condition,  however,  re- 
mained within  the  limits  of  physiologic  depression.  The  patient  became  mis- 
erable, ate  and  slept  little,  felt  tired,  and  was  fatigued  easily  at  work,  but 
kept  at  his  employment  and  comforted  his  wife  about  their  loss. 

On  account  of  increasing  physical  weakness,  he  nf)w.  in  contrast  with  nis 
usual  habit,  drank  more  wine,  without,  ho\ve\cr,  becoming  Intoxicated.  He 
read  much  in  religious  books  to  gain  encouragement,  even  late  into  the  night. 

From  the  middle  of  April  there  was  bad  sleep  disturbed  with  impleasant 
dreams,  oppression,  nervous  rmrest,  and  inconstancy.  He  became  very  irri- 
table and  quarreled  with  others  about  the  comprehension  and  significance  of 
certain  passages  in  his  religious  books. 

April  -ZSth,  after  a  sleepless  night,  liallucinations  developed:  patient  saw 
hell  open  and  shut,  saw  condemned  souls,  then  again  Heaven  opened,  and  he 
thought  that  he  Imd  become  a  child.  At  times  he  Avas  apprehensive  and  weep- 
ing; at  other  times  joyfidly  excited.  He  slept  no  longer,  and  finally  said  that 
he  was  God,  who  was  in  him  and  spoke  through  him.  He  said  that  he  was  no 
longer  alive  and  that  if  he  were  alive  he  would  not  exist.  To  those  about  him 
he  promised  eternal  happiness  and  blessedness. 

The  patient  goes  about  confused,  v/ith  no  idea  of  place,  his  expression  dis- 
turbed, and  with  weeping,  apathetic  manner.  In  a  confused  way,  and  with 
affected  speech,  he  speaks  of  fights  and  frightful  vision  which  he  had  had, 
with  internal  pains  in  his  chest  and  feelings  of  anxiety.  He  soon  became  ii-ri- 
table,  threw  his  spoon  at  other  patients,  saying  that  no  one  should  come  near 
him,  and  tore  the  bedclothes  off  the  bed.  He  is  full  of  illusions  and  hallucina- 
tions, and  passes  the  two  following  nights  without  sleep,  presenting  mainly  a 
religious  expansive  delirium,  intermingled  with  demoniac  ideas.  He  suddenly 
mistakes  the  physician  for  Satan,  and  cries  with  a  voice  of  thunder:  "Away 
from  me."  He  becomes  aggressive,  and  it  is  therefore  necessary  to  isolate 
him.  He  happened  to  be  seen  holding  in  his  hand  a  hair  which  he  had  found 
in  the  bread,  and  saying  that  it  was  a  hair  of  his  departed  father;  at  night 
he  is  A^ery  restless  and  has  innumerable  hallucinations  of  sight  (sleight  of 
hand,  shadow-pictures,  biblical  forms  on  the  Avall  the  size  of  children). 

The  patient  is  of  medium  size,  much  reduced  in  general  health,  pale,  and 
anemic.  The  tongue  shows  the  tremor  of  inanition;  the  pulse  is  small,  poorly 
filled,  and  108;   no  fever,  no  vegetative  disease,  and  no  signs  of  degeneration. 

The  patient  slept  the  night  of  April  9th  after  morphine  and  chloral.  The 
9th  he  is  quieter  and  less  confused,  but  he  refers  to  evil  spirits  which  he  saw 
yesterday,  to  Satan  Avho  sat  at  table  in  the  form  of  an  orang-outang,  of  the 
sacrament  which  he  had  partaken  of,  and  Avonderful  flames  of  fire  which  he 
had  seen  on  waking  up.  With  good  nights  and  rich  food  the  mind  clears  up 
rapidly  and  the  hallucinatory  delirium  disappears. 

As  early  as  April  12th  he  had  some  idea  of  his  past  condition. 

The  patient  finds  the  cause  of  his  disease  to  be  sorroAV  at  the  death  of  his 
last  child  and  diminution  in  his  ability  to  earn  money  in  his  occupation.     Too, 


350  SPECIAL  PATHOLOGY  AND  THEI^vAPY  OF  INSANITY. 

he  had  eaten  very  little,  slept  poorly,  and  been  reduced  in  strength,  always  in- 
creasin«^  in  his  preotiupation  with  religion  and  in  drijiking.  Une  day,  the 
17th  of  April,  everything  seemed  to  him  to  l>e  changed.  The  nature  of  time 
seemed  altered.  At  one  time  the  night,  at  another  the  day,  seemed  too  long. 
One  day  he  foiind  a  pieture-nail,  then  later  a  board  was  dug  up  in  tlie  court 
whieh  had  a  cadaveric  odor.  The  llowering  trees  seemed  changed  to  him.  Tlic 
sun  shone  peculiarly  when  setting,  and  various  objects  had  a  cadaveric  odor. 
About  April  2Slh  one  night  ne  noticed  the  ticking  of  a  wall-clock  whicli  did 
not  exist,  and  he  thought  tluit  the  last  hour  had  come,  lie  saw  llanies,  hell 
open,  the  condemned,  and  cont»'ssc<t  and  took  communion  on  the  morning  of 
the  29th.  lie  was  constantly  more  confused,  and  the  I'nlldwing  night  saw 
innumerable  Satanic  forms.  He  lost  all  courage,  especially  because  his  wife 
seemed  very  strange  to  him.  Everything  seemed  to  be  distorted.  He  thought 
of  the  end.  of  the  wmlil,  of  the  la>t  judginciil,  and  he  had  constantly  the 
o<lor  of  putrefaction  in  Jiis  nostrils.  Then  there  were  pleasant  odors.  It 
seemed  to  him  as  if  the  old  saints  were  rising  from  the  dead;  as  if  he  were 
attached  to  the  earth,  which  wa.s  whirling  through  space.  He  had  divine 
visions  ami  (Icliriuin;  thoiighl  himself  one  with  God,  but  occasionally  heard 
anxious  voices  calling. 

The  patient  relates,  further,  that  on  account  of  care  fur  liis  young  chil- 
dren he  had  abstained  from  intercourse  for  three  years,  substituting  onanism 
for  it.  No  epileptic  antecedents.  The  patient  is  still  exhausted,  comi)lains 
much,  and  is  easily  frightened.  He  soon  gains  complete  insight  into  his  dis- 
ease, and  recovers  quickly  with  good  nursing,  and  is  discliaiged  cured  June 
27th.     The  recovery  has  been  maintained. 


CHAPTER  V. 
Secondary  Insanity  and  Terminal  Dementia.^ 

The  sad  terminatiou  of  all  psychoncn roses  that  do  uot  go  on 
to  recovery  is  a  progressive  destruction  of  the  psychic  existence,  a 
disintegration  of  the  personality,  np  to  that  time  a  nnit  historically 
and  in  content.  This  tragic  process  of  psychic  decay  before  phys- 
ical death  sometimes  takes  place  with  extreme  rapidity,  especially 
in  furious  mania;  sometimes  it  occurs  very  gradually.  First  the 
ethic  and  then  the  intellectual  faculties,  especially  memory  and 
logical  powers,  become  defective,  until  finally  the  faculties  of  ap- 
perception and  associated  affective  manifestations  have  disappeared; 
and  of  the  former  being,  as  an  exauiple  of  human  existence,  there 
finally  remains  ouly  the  physical  hull,  witli  its  automatic  and  purely 
vegetative  functions. 

The  physiognomy  of  the  patient  gives  an  early  sign  of  the  on- 
coming psychic  destruction.    It  takes  on  a  peculiar,  distorted  char- 


'  Incurable  terminal  stages  of  the  psyclioneuroses — states  of  secondary 
psychic  weakness. 


PSYCIiONKüROSES— rRIMAllY  CUüAßF.E  STATKS.  351 

aetei';,  partly  due  to  inequality  in  the  innervation  of  the  homologous 
groups  of  muscles;  partly  due  to  contracture  in  the  muscles  of  ex- 
pression. As  result  of  this  the  physiognomy  becomes  somewhat  aged., 
distorted;  and  with  the  changed  and  strained  condition  of  the  eyes, 
which  renders  the  glance  peculiarly  fixed,  there  is  something  wierd 
in  the  facial  expression. 

With  the  occurrence  of  the  stage  of  dementia  the  pliysiognomy, 
in  which  tliere  is  no  longer  any  emotiojiai  expression  and  no  evidence 
of  psychic  activity,  takes  on  a  negative,  empty  character. 

The  disturbance  of  sensorial,  vasomotor,  and  vegetative  func- 
tions, so  often  evident  in  states  of  affective  insanity,  disappears  in 
these  states  of  psychic  weakness.  The  vegetative  processes,  sleep, 
nutrition,  etc.,  present  no  decided  disturbance  when  there  is  no 
co-existing  somatic  complication. 

On  the  other  hand,  there  are  many  forms  of  trophic  disturbance 
the  significance  of  Avhich,  as  yet,  is  more  or  less  imperfectly  under- 
stood, the  general  effect  of  which,  however,  is  comparable  with  that  of 
precocious  senility;  for  these  patients  look  older  than  they  actually 
are.  These  dystrophies  and  atrophies  express  themselves  especially 
in  precocious  grayness  of  the  hair,  disappearance  of  subcutaneous 
adipose  tissue,  dryness  and  defective  freshness  of  the  skin,"  with  slow 
circulation  in  the  capillaries,  tendency  to  edema,  pityriasis,  hema- 
toma of  the  ear,  fatty  degeneration  of  the  organs  (especially  the 
heart),  and  precocious  arteriosclerosis. 

This,  in  part,  exjolains  the  marasmus  and  the  reduction  of  the 
average  length  of  life  among  insane  patients.  It  seems  almost  im- 
possible in  these  individuals,  who  j)resent  qualitatively  and  quanti- 
tatively the  most  varied  pictures  of  psychic  disintegration,  to  distin- 
guish general  clinical  disease-pictures.  However,  two  fundamental 
states  msLj  be  differentiated : — 

1.  Secondary  delusional  insanity. 

2.  Terminal  dementia,  with  its  two  clinical  varieties:  (aj  Agitated. 
(dj  Apathetic. 

1.  Secondaky  Delusional  Insanity. 

Under  this  heading  may  be  grouped  all  the  psychic  conditions 
in  which  the  duration  of  ideas  developed  in  a  primary  affective  insan- 
ity continue  to  exist,  after  the  disappearance  of  the  affect  which 
accompanied  their  origin,  as  a  lasting  error  of  the  understanding,  as 
a  more  or  less  stationary  abnormal  group  of  ideas;  and  thus  they 
make  up  an  entirely  new  personality  and  entirely  different  relations 
of  life  from  those  which  characterized  the  former  normal  ego. 


3:)*:?        SPECIAL  pat[I(it.O(;y  and  tiif.uapy  of  insamtv. 

x\t  the  same  time  there  exists,  however,  another  important 
disturbance:  the  absence  of  impnlse  to  act  in  accordance  with  the 
delusional  ideas  still  present  in  consciousness. 

There  is  especially  absence  of  the  peculiar  accord  of  feeling, 
thought,  and  will  which  characterizes  affective  insanit)'.  The  unity 
of  the  psychic  personality,  the  ego,  is  never  retained.  The  united 
historic  ego  is  divided  up  into  as  many  egos  as  there  are  groups  of 
delusional  ideas,  and  it  is  vain  to  attempt  in  this  disintegration  to 
bring  into  even  the  most  superficial  relation  these  delusions,  whose 
content  may  be  completely  contradictory  and  diametrically  opposite 
to  the  laws  of  time,  space,  logic,  and  experience. 

This  striking  absence  of  desire  to  explain  the  dilfcrences,  to 
account  for  the  contradictions,  indicates  a  profound  weakening  of 
all  the  higher  intellectual  faculties:  judgment,  logic,  and  often 
also  memory. 

Intellectual  activity',  such  as  was  possil)le  Ijciorc  the  disease,  <u- 
objective  and  creative  activity  in  accordance  with  a  plan,  is  thus  im- 
possible. The  patient  moves  within  the  circle  of  his  fixed  ideas;  and 
his  idea  of  self  and  the  external  world  is  totally  changed. 

To  be  sure,  the  patient  is  still  able  to  converse  to  some  extent, 
for  the  mechanism  of  formal  thought  still  remains  and  is  no  longer 
disturbed  by  emotion,  and,  too,  because  he  still  has  at  command 
nimierous  remains  of  his  previous  normal  life;  but  of  real  intel- 
lectual sharpness  and  humor  there  can  no  longer  be  any  question. 
A  well-ordered  mental  activity  is  impossible  in  a  case  of  secondary 
insanit}"",  because,  with  al)normal  insistence,  the  individual  always 
returns  to  the  circle  of  his  fixed  ideas  and  is  forced  to  think  in  it. 

The  ethic  indilference  and  emotional  defect  of  this  category  of 
patients  is  especially  striking.  The  whole  past  life,  with  its  emo- 
tional relations  to  the  family  and  friends,  has  become  quite  foreign; 
and  they  are  quite  as  insensitive  to  the  w^elfare  of  those  about  them. 
It  is  only  that  which  directly  concerns  the  nucleus  of  their  delusional 
ideas,  whether  it  be  favorable  or  unfavorable,  that  can  still,  at  least 
in  the  beginning,  induce  emotional  reaction;  but  in  the  course  of 
time  the  emotional  excitability  for  even  the  circle  of  abnormal  ideas 
disappears,  and  indefinite  delusions,  darker  in  their  significance  for 
consciousness,  finally  become  incomprehensilile  and  are  reproduced 
without  emotional  accompaniment,  as  soon  as  external  impressions 
or  processes  of  association  call  them  into  consciousness. 

In  the  most  extreme  degree  of  secondary  insanity  (in  transition 
to  general  confusion)  there  is  a  senseless  and  disconnected  appear- 
ance and  reappearance  of  ideas  in  consciousness  which  are  imper- 


PSYCHONEUROSES— PRIMARY  CUKAliLE  STAT]':S.  353 

fectly  held  together  by  the  unity  of  the  fixed  idea.  In  such  insane 
persons  there  are  still  frequently  hallucinations,  or  at  least  lively 
ideas  which  recall  constantly  the  circle  of  delusional  ideas;  hut  here 
also  there  is  weakness — there  is  no  longer  anything  new  produced,  in 
contrast  with  the  actively  creative  fantastic  and  logical  delusions 
which  occur  in  affective  insanity  and  in  primary  delusional  insanity. 

The  delusion  of  the  secondary  maniac  remains  dead,  incapable 
of  any  essential  modification  of  idea,  which,  with  the  progressive 
deterioration  of  mental  life,  is  reduced  more  and  more  to  a  mere 
phase,  to  an  indifferent  content  in  which  there  is  no  longer  any 
impulse  to  realize  that  which  is  felt  and  thought  in  delusion. 

Secondary  insanity  is  the  ordinary  termination  of  melancholic 
insanity  with  delusions  if  it  does  not  pass  on  to  recovery ;  much  less 
frequently  secondary  insanity  is  the  termination  of  mania,  since  in 
mania,  owing  to  the  rapid  course  of  the  psychic  activities,  the  fixation 
of  delusions  and  their  systematization  are  only  rarely  possible. 

Such  conditions  of  secondary  insanity  remain  sometimes  for 
many  years  at  the  same  stage,  until  finally  mental  weakness  takes 
more  and  more  the  upper  hand,  and  delusions  become  less  and  less 
definite  in  content  and  form. 

Eecognition  of  such  conditions  as  of  secondary  nature  may  pre- 
sent difficulties,  when  the  previous  history  of  the  cases  is  not  at 
hand.  However,  prolonged  observation  will  reveal  particular  features. 
The  increasing  emotional  defect,  the  predominant  confiision  and  in- 
coherence of  mental  life,  and  the  want  of  all  ethic  and  social  ideas 
(un cleanliness),  which  may  go  on  to  the  degree  of  mere  animal  mental 
activity,  lend  distinctive  characteristics. 

In  cases  that  terminate  melancholia  there  are  remains  of  de- 
lusional ideas,  occasionally  states  of  apprehension,  raptus,  and  other 
evidences  of  the  primary  stage;  in  cases  terminating  mania,  there 
are  maniacal  relapses,  which,  even  in  the  advanced  stages  of  de- 
mentia, may  make  their  reappearance. 

Case  19. — Furious  mania;   termination  in  secondary  insanity. 

G.,  peasant,  aged  29;  her  father  was  insane  and  is  said  to  have  been 
peculiar  and  irritable  from  his  childhood.  Early  in  1876  she  married.  With- 
out any  known  cause,  after  a  melancholic  attack  of  two  weeks  in  the  begin- 
ning of  August,  1876,  she  became  maniacally  excited  and  rapidly  became 
furious.     The  patient  commenced  to  pray,  sing,  destroy,  and  to  undress  herself. 

On  admission  she  was  in  a  state  of  great  exaltation,  spoke  high  German, 
preached  improvised  sermons  with  pathos,  spoke  in  biblical  sentences,  a.nd 
catechised  those  around  her.  In  this  there  was  alliteration  and  rhyming: 
"Der  Himmel  ist  ein  Schimmel,  der  Schimmel  ist  ein  Lümmel,  Alles  soll  klingen 
und  singen  und  springen." 


354  SrECIAL  PATIIOLOOY  AXD  TIIKKAPY  OF  INSAXITV. 

In  her  expansive  ideas  there  is  the  nucleus  of  erotic  religious  delusions. 
She  is  the  Queen  of  Heaven,  the  Virgin  of  Infinite  Health,  full  of  desire  and 
strength.  All  about  her  is  Monderful  in  beauty.  All  should  rejoice  with  her — 
she  has  lived  all  things,  is  a  child,  a  maiden,  rich  and  poor,  distinguished  and 
unknown;  she  has  put  out  tlie  lircs  of  liell  and  purgatory,  and  delivered  the 
whole  world.  Cod  the  Fatlior  and  Ciod  the  motlier  liavc  shown  themselves  to 
her  in  clouds.     The  patient  dances",  sings,  cries,  and  claps  licr  hands  with  joy. 

Ears  small,  badly  dillcrcntiatcd;  pupils  dilated,  reacting  lazily.  Pulse, 
100;    bad  nutrition ;    evident  anemia;    uterus  witliout  abnormality. 

The  patient  is  sleepless,  easily  congested,  salivated,  dances,  prays,  sings, 
is  erotically  excited,  likes  to  luidress  herself  and  arrange  her  hair,  and  urinates 
on  the  floor  at  the  time  of  the  visit. 

She  has  borne  five  children,  one  being  the  Saviour.  She  is  the  Queen  of 
Heaven;  she  takes  those  around  her  for  divine  personages;  has  numerous 
auditory  and  visual  hallucinations,  is  occupied  with  joyful  feelings,  and  from 
time  to  time  falls  into  states  of  ecstasy  in  which  she  prays. 

Trcatctl  with  chloral  and  potassium  bromide  (8  grams)  and  isolation,  the 
maniacal  condition  diminishes,  but  there  remains  a  marked  state  of  increased 
feeling  of  self,  expressed  in  affected  literary  language  and  afl'ected  manner, 
and  the  delusions  remain  uncorrected.  The  patient  becomes  quiet,  occupies  her- 
self with  handwork.  Only  at  the  time  of  the  menses  is  she  excited,  praying 
and  acting  as  if  she  were  Mary  the  Queen  of  Heaven  and  had  given  birth  to 
the  Saviour.  She  mistakes  those  about  her  for  harlots  and  the  devil,  and 
rages  and  becomes  aggressive  toward  them. 

There  is  a  progressive  development  of  a  condition  of  erotic  religious  in- 
sanity, which  becomes  more  and  more  evident.  The  delusions  become  more 
and  more  confused.  She  was  an  angel,  had  laid  eggs  upon  which  she  lived,  was 
father  and  mother  at  the  same  time.  When  she  was  an  angel  she  had  carried 
St.  John  into  the  presbytery,  where  he  had  eaten  to  the  amount  of  thirty 
pieces  of  silver.  She  had  risen  six  times  to  Heaven  and  had  assisted  six  times 
at  the  consecration  of  an  emperor.  Maria  Theresa  was  her  grandmother.  The 
angels  in  Heaven  were  made  of  gold  and  precious  stones.  When  she  came 
back  to  earth  she  became  a  porcupine.  She  herself  is  holy  and  has  given  birth 
to  five  angels,  etc. 

Former  normal  relations  of  life  have  become  foreign  to  the  patient.  Her 
present  delusions  are  no  longer  associated  with  lively  emotional  states.  It  is 
only  when  she  is  contradicted  or  questioned  that  she  becomes  angry  and  says 
that  her  questioner  is  Lucifer  the  enemy,  heaps  invectives  upon  him,  and  calls 
down  upon  him  divine  anger,  to  suddenly  fall  into  silly  laughter  and  eroticism. 
Usually  she  is  quiet  with  affected  manners.  The  affected  speech  in  high  Ger- 
man, the  inclination  to  adorn  herself  in  dress  and  hats,  indicate  the  deep 
mental  disturbance.  Logical  foimdation  and  connection  of  delusions,  which 
are,  for  the  most  part,  based  upon  ecstatic  visionary  states  and  hallucinations, 
do  not  exist.  During  the  last  two  years  the  patient  has  produced  nothing 
new;  on  the  contrary,  her  delusions  have  become  more  and  more  imperfect, 
fragmentary,  and  less  easily  excited.  A  progressive  state  of  mental  weakness 
is  unmistakable. 


PS YCHONEUROSES— PRIMARY  CURAJJl.K  STATES.  355 

2.    TiiUMlNAij   DkmKNTJA. 

The  final  results  of  psychoses  wJiich  do  not  go  on  to  recovery, 
if  the  patients  live  long  enough,  arc  states  of  dementia.  They  are 
the  expression  of  organic  changes  in  the  cortex  which  arc  comprised 
in  the  term  atrophy. 

In  accordance  with  the  nature  of  tlie  anatomic  pi-ocess,  the  de- 
mentia may  come  on  with  great  rapidity,  as  after  severe  furious 
mania,  or  gradually  in  the  course  of  years,  as  in  the  final  stage  of 
paranoia.  Clinically  there  are  innumerable  variations  with  reference 
to  the  intensity  and  extent  of  psychic  weakness  up  to  apathetic 
dementia. 

In  the  concrete  case  we  must  examine  the  various  functions  of  intel- 
lectual life,  especiall}'  the  kind  and  extent  of  the  ethic  and  esthetic  activities; 
the  keenness  of  judgment  and  logic;  the  degree  of  want  of  energy  of  the  will; 
the  rapidity  or  slowness  of  apperception,  combination,  and  action;  the  power 
of  memory  with  reference  to  its  various  qualities,  and  thus  establish  the 
measure  of  the  degree  of  mental  weakness.  Slighter  degrees,  such  as  occur  not 
infrequently,  especially  after  severe  melancholias  and  manias,  frequently  escape 
observation.  Slight  lowering  of  mental  power  often  does  not  show  itself  in 
the  asylum,  Avhere  the  recovered  patient  is  strikingly  above  the  level  of  other 
patients  and  accustomed  to  his  surroundings;  and  it  only  becomes  clear  when 
the  recovered  patient  is  discharged  and  tries  to  employ  his  restored  force  in 
public  and  professional  life.  The  more  difficult  and  the  higher  the  station  in 
life,  the  more  clearly  does  the  loss  appear  which  the  patient  has  undergone  as 
result  of  his  disease,  even  though  his  mental  capability  still  surpasses  the 
average  man  unblessed  with  higher  mental  gifts. 

Only  a  close  observer,  who  knew  the  patient  before,  notices  that  he  has 
sustained  injury,  especially  in  his  ethic  feeling;  that  he  is  indifferent  with  ref- 
erence to  many  life  relations  which  he  formerly  held  in  high  regard;  duller  in 
his  emotion,  more  lax  in  his  moral  principles,  more  easily  influenced,  and  less 
energetic  in  his  activity.  If  there  be  also  less  accuracy  of  memory,  slowing  of 
activity,  less  pleasure  in  work,  and  change  of  character  in  the  sense  of  being 
more  irritable,  then  the  psychic  weakness  is  still  clearer  and  not  unimportant 
from  a  medical  standpoint,  in  that  such  weakened  individuals  have  suffered 
damage  in  their  moral  motives,  are  easily  influenced  in  their  acts,  and  can 
offer  less  resistance  to  their  emotional  impulses. 

With  reference  to  the  pronounced  final  stages  of  secondary  de- 
mentia, two  clear  clinical  pictures  may  be  differentiated : — 

(a)  Affitated  Dementia  (General  Mental  Confusion). 

In  this  condition  there  are  still  certain  psychic  elements  remain- 
ing; there  are  still  ideas  and  impulses,  but  they  form  part  of  a  dis- 
integrated mental  mechanism,  the  single  elements  of  which  have 


3ÜG  SPECIAL  PATIlol.OdV   AND  Tlli:i;Al'Y  Ol'  INSANITY. 

become  autononioiis  ami  can  no  longer  be  united  into  a  sini;io  con- 
sciousness— into  an  ego.  The  ideas  of  such  a  patient  are  absolutely 
vague,  planless,  accidental,  arising  out  ot  superlicial  similarity  of 
sounds  or  absolutely  devoid  of  ideational  association.  Even  the  log- 
ical sense  of  Avords  has  become  foreign  to  the  patient.  He  speaks 
■words  that  are  without  signilicancc  to  him,  and  that  represent 
nothing  more  than  juere  shells  of  words:  the  remains  of  former  con- 
cepts and  ideas  of  movement. 

In  his  agitation  and  his  confused  volubility  the  patient  resembles 
a  maniac,  but  this  resemblance  is  very  superficial.  Instead  of  lively 
emotion  like  that  of  the  maniac,  there  is  merely  a  demented  play  of 
features  expressed  in  ejnpty  laughs  or  whining  grimaces,  and  child- 
ish, silly  conduct.  While  in  the  maniac,  even  at  the  height  of  his 
incoherence,  there  are  connected  groups  of  ideas,  logical  connections 
and  associations,  the  incoherence  of  agitated  dementia  is  without 
foundation  and  usually  devoid  of  all  association. 

"While  in  the  remissions  of  mania  the  former  complete  mental 
force  shines  forth,  in  dementia,  behind  all  the  noise  and  disturbance 
with  which  the  defective  mechanism  acts,  there  is  nothing  but  the 
darkness  of  dementia. 

In  this  condition,  in  spite  of  all  the  activity,  combination  of  the 
disparate  and  defective  ideas,  a  judgment,  or  a  purposeful  act  is  no 
longer  possible. 

Finally,  mania  is  a  temporary  remittent  condition,  while  agitated 
dementia  is  a  terminal  pernumcnt  state. 

Such  terminal  manifestations  of  general  confusion  are  princi- 
pally the  final  stage  of  hallucinatory  insanity;  also  of  manias,  with 
mania-like  transitional  stages,  that  have  not  gone  on  to  recovery. 

(h)  Apalliclic  Demeiilia. 

The  most  extreme  degree  of  psychic  deterioration  is  the  condi- 
tion of  apathetic  dementia,  which  results  directly  from  severe  unre- 
covered  melancholias,  especially  of  the  active  and  stuporous  varieties, 
from  attacks  of  severe  mania,  and  from  acute  dementia.  In  such 
cases  the  physiognomy  has  the  expression  of  complete  nullity.  The 
innervation  of  the  extensors  is  quite  paralyzed,  so  that  the  body 
obeys  only  the  law  of  gravity,  and  thus  the  attitude  is  determined. 
The  chin  sinks  on  the  breast,  the  limbs  take  on  a  slightly  flexed 
position,  and  the  saliva  runs  from  the  mouth. 

Mentally  there  is  complete  quiet,  apperception  is  reduced  to 
mere  perception,  and  sensibility  and  reflex  excitability  are  reduced  to 


PSYCHONEUEOSES— PRIMARY  CURABLE  STATES.  3,57 

a  minimmn.  Owing  to  the  loss  of  all  the  mental  powers,  such  im- 
fortunate  patients  are  like  animals  that  have  been  deprived  of  the 
cerebrum,  and  the  fact  is  that  their  cortex  is  devoid  of  function. 
They  no  longer  feel  hunger,  and  take  no  account  of  danger;  they 
must  be  fed,  dressed,  and  cared  for  or  they  would  die.  In  the  most 
profound  degrees  of  this  condition,  with  the  loss  of  concepts,  there  is 
also  loss  of  ideas  of  movement,  and  under  such  circumstances  speech 
ceases  and  there  is  true  amnesic  aphasia..  This  mental  death  may 
sometimes  continue  for  years  before  physical  death  comes  as  a  de- 
liverance. In  general,  such  unfortunates  do  not  live  very  long,  for 
either  the  paralysis  of  the  psychic  centers  progresses  to  the  centers 
of  respiration  and  circulation  or  the  absence  of  movement  and  suffi- 
cient respiration  induces  decided  disturbance  of  circulation  and  nutri- 
tion, and  the  fatal  termination  is  broiight  about  by  pneumonia, 
colliquative  diarrhea,  etc. 

Case  30. — Furious  mania;  termination  in  apathetic  dementia. 

K.,  aged  28,  shoemaker,  illegitimate,  said  to  be  without  hereditary  taint. 
From  youth  up  he  was  timid,  unsociable,  and  easily  frightened,  but  he  was 
mentally  well  endowed.  At  about  the  age  of  19  (puberty)  he  had  an  attack 
of  melancholia.     He  recovered  completely  in  six  months. 

At  the  end  of  June,  1873,  he  came  to  his  parent's  house  one  evening  dis- 
turbed and  excited.  He  was  sleepless  and  hasty  in  his  movements.  His 
excitement  increased,  and  he  had  flight  of  ideas,  was  incoherent,  and  said  he 
was  the  King  of  Germany,  and  the  tight-rope  dancer  was  the  queen  whom  he 
wished  to  marry.  He  was  Adam,  St.  John,  and  the  Saviour  of  the  World. 
The  Schiller  bell  was  the  most  beautiful.  He  began  to  sing,  whistle,  swear, 
scold,  and  slammed  doors  and  windows,  beat  his  relatives,  saw  fire  in  the  air, 
the  devil  heard  him  call,  and  he  thought  he  was  to  be  burned,  to  be  decapi- 
tated. He  ate  nothing,  had  very  great  thirst,  and  suffered  Avith  constipation. 
The  patient  Avas  admitted  in  a  state  of  fully  developed  furious  mania  July 
7,  1873. 

His  thought  had  become  a  flight  of  ideas  with  incoherence.  At  times 
there  were  delusions  of  being  the  Saviour  and  John  the  Baptist.  Conscious- 
ness was  profoundly  disturbed.  The  motor  impulsiveness  continued  and  was 
directed  only  to  destructiveness.  The  patient  had  numerous  visual  and 
auditory  hallucinations  (devil,  God,  etc.).  Patient  was  without  fever,  and  the 
pulse  rarely  increased  above  80.  Vegetative  organs  Avere  intact.  Aside  from 
a  considerable  prominence  of  the  occiput  there  Avere  no  cranial  anomalies. 

The  motor  excitement,  the  incoherence  of  ideas,  and  the  hallucinations, 
in  spite  of  prolonged  baths,  continued  several  weeks  at  the  same  degree  of 
intensity.  Then  profound,  but  short,  remissions  occiu-red,  followed  by  more 
violent  exacerbations. 

After  lasting  five  months,  during  Avhich  the  patient  was  much  reduced 
in  general  condition,  the  mania  gaA'e  place  gradually  to  quiet  and  profound 
exhaustion.  The  patient  remained.  hoA\'eA'er.  confuted  and  unclean,  but  noAV 
and  then  there  was  silly,  childish  emotion,  and  he  Avould  remain  for  hours  at  a 


3-,S  SPECTAL  PATTIOLOr.Y  AXD  TT1!•^AP^    OF  INSANITY. 

tinu-  in  strange  positions.  He  showed  no  lunger  any  reaction  to  external 
stimuli,  not  even  to  the  strongest  faradic  currents.  His  face  took  on  an  ex- 
pression of  complete  nullity.  The  eyes  stared  into  space,  the  attitude  became 
relaxed,  and  saliva  llowed  from  the  mouth.  Thcro  was  no  longer  any  reaction 
n  speech,  and  there  was  great  increase  of  fa,.  A,  Ihc  end  of  1874  the  patient, 
in  a  state  cf  .on.plctc  aiuUhctic  den.cnliu,  nsu.  Iranslcrred  to  au  institution 


for  iucurables. 


PART  SECOND. 
Psychic  Degenerations. 


CHAPTER  I. 
General  Clinical  Consideration. 

The  etiologic  and  anthropologic  separation  of  these  psychopathic 
states  has  been  referred  to  in  the  introduction  (classification),  and 
their  peculiar  course  and  clinical  manifestations  were  emphasized  in 
contrast  with  those  of  the  psychoneuroses.  Before  considering  or  at- 
tempting to  describe  these  states  of  degeneration,  which  vary  so  much 
individually,  it  seems  best  to  give  a  general  description  of  the  various 
manifestations  of  an  abnormal  central  nervous  system  whose  func- 
tions are  so  frequently  perverted.  These,  for  the  most  part,  are  com- 
prehended in  the  term  neuropathic  constitution,  with  irritable  weak- 
ness, which  already  in  the  discussion  of  etiology  has  been  met  as  an 
important  predisposing  cause  of  insanity.  The  signs  of  this  neuro- 
pathic constitution  vary  extremely  with  the  individuals.  It  can  only 
be  said  in  general  that  in  such  abnormally  organized  persons  the 
central  nervous  system  shows  small  resistive  power,  abnormal  im- 
pressionability, and  is  prone  to  exhaustion,  and  that  the  cerebral 
functions,  including  those  of  mind,  manifest  themselves  partly  with 
abnormal  force,  partly  in  a  distorted  or  perverse  manner. 

On  the  etiologic  side  it  is  to  be  noted  that,  for  the  most  part, 
such  persons  come  from  parents  who  were  insane,  nervous,  of  ab- 
normal character,  or  given  to  drink;  or  they  were  affected  in  early 
life  by  constitutional  diseases,  such  as  rickets,  which  had  an  injurious 
effect  upon  the  development  of  the  brain  and  cranium  (hydrocephalic 
conditions).  Often,  too,  grave  spontaneous  affections  of  the  brain, 
such  as  meningeal  hyperemia  and  encephalitic  diseases  or  abnormal 
conditions  due  to  traumatism,  may  produce  similar  results.  Finally, 
onanistic  irritation,  which  injures  the  brain  in  its  organic  and  func- 
tional evolution  during  the  period  of  its  development,  may  have  a 
similar  effect.  When  the  injury  has  been  severe  and  the  development 
is  not  arrested  with  the  production  of  idiocy,  the  further  develop- 

(359) 


3G0  SPECIAL  PATIIOLOC'Y  AND  TIIKRAPY  OF  INSANITY. 

ment  is  abnormal,  and  often  lakos  a  perverse  direction.  This  taint 
then  makes  itself  apparent  partly  in  the  general  cerebral  domain 
in  signs  of  fnnctional  degeneration,  and  parti}'  in  the  special  ps^'chic 
domain  in  anomalies  of  development  of  character,  in  morals  and  in- 
stinctive life,  while  the  intellectual  activities  alone  attain  a  state  of 
good  devclopiiient.  The  expression  '•])sychic  degeneration"  has  no 
anatomic  signilirancc  in  the  sense  of  a  degeneration  of  the  cortex 
as  the  organ  of  the  psychic  functions,  but  simply  indicates  that 
functionally  there  is  a  permanent,  abnormal  and  often  perverse  and 
progressive  deviation  from  the  noi'mal  average  of  cerebral  and  psy- 
chic activity,  because  it  is  founded  in  the  constitution — there  is  a 
deviation,  a  degeneration,  of  the  general  personality.  The  expression 
is  also  justified  by  the  fact  that  we  speak  of  a  man  morally  degen- 
erate. This  psychic  degeneration,  however,  has  a  more  profound 
pathologic  foundation,  because  often  it  can  be  referred  to  distinct 
cerebro-pathologic  conditions,  and  often  enough  is  associated  with 
anatomic  signs  of  degeneration.  Besides,  this  psychic  degeneration, 
from  the  anthropologic  standpoint,  is  a  very  important  manifestation; 
for  in  the  individual  it  is  only  a  single  link  in  the  chain  of  physical 
and  psychic  processes  of  degeneration  which  affect  the  whole  family 
and  pass  thi'ough  generations,  becoming  more  and  more  pronounced 
in  its  forms  as  time  goes  on. 

The  anomaly,  which  is  largely  a  perversion  of  functions  of  the 
central  organ,  is  especially  expressed  in : — 

(a)  The  domain  of  the  vital  processes,  as  great  morbidity,  less- 
ened longevity,  unusual  reaction  to  atmospheric  and  telluric  and 
alimentary  injurious  influences;  greater  height  and  remarkable  ir- 
regiüarity  of  the  temperature  curve  in  febrile  diseases  with  otherwise 
typic  course  and  temperature;  in  great  nervous  excitability  going 
even  to  the  extent  of  severe  neurotic  symptoms  (convulsions,  neu- 
roses, psychoses)  during  the  physiologic  phases  of  life  (dentition, 
puberty,  menses,  climacteric);  in  the  early  occurrence  of  puberty, 
especially  early  mental  and  physical  development,  associated  with 
weakness,  physical  delicacy,  clear  complexion,  iN'mphatic  constitution, 
and  tendency  to  scrofulous  diseases  in  childhood  and  later  to  tuber- 
culosis. Frequently  in  such  cases,  arising  at  the  time  of  puberty, 
there  are  conditions  of  profound  constitutional  anemia  and  chlorosis 
but  slightly  amenable  to  treatment. 

(h)  In  the  domain  of  the  general  cerebral  functions  there  is 
unusually  intense  concomitant  affection  of  the  central  nervous  system 
in  cases  of  slight  physical  diseases,  in  the  form  of  somnolence, 
stupor,  delirium,  hallucinations,  etc. 


PyVCIlIC  DECiENEllATKJXS.  301 

(c)  In  the  sensory  domain  there  is  almonnal  toii(h;ncy  to  ex- 
citement, with  unusual  duration  oi'  excitciiiont  and  irradiation  to 
distant  neural  territories. 

(d)  In  the  domain  of  the  sensorium  there  is  tendency  to  hyper- 
esthesia, usually  manifested  in  intensity  of  impressions,  of  pleasure 
or  aversion,  leading,  through  ease  in  perversion  of  these,  to  idio- 
syncrasies. 

(e)  The  instability  of  the  vasomotor  innervation  shows  itself  in 
its  intense  manifestations  simultaneously  with  psychic  excitement 
(paleness,  blushing,  palpitation,  precordial  sensations)  and  other  in- 
fluences which  reduce  the  tone  of  the  vasomotor  nerves  (heat, 
alcohol).  As  a  rule,  such  individuals  react  with  an  abnormal  and 
unusual  intensity  to  alcohol.  At  the  same  time  the  functional  weak- 
ness of  the  nerve-centers  frequently  induces  an  inclination  to  indulge 
in  this  stimulant.  Under  its  deleterious  influence,  on  the  basis  of 
the  organic  taint,  the  most  severe  forms  of  functional  degeneration 
develop. 

(f)  The  functional  signs  of  degeneration  in  the  motor  domain 
are  nystagmus,  strabismus,  stuttering,  contractures,  and  other 
anomalies  of  muscular  innervation,  especially  in  the  face  (grimaces, 
tics),  and  the  most  marked  indications  of  taint — epileptic  and  epilep- 
toid  attacks. 

(g)  The  sexual  instinct  in  particular  is  very  frequently  abnor- 
mal. It  may  be  either  entirely  wanting  or  abnormally  intense  in  its 
manifestation,  impulsively  seeking  satisfaction;  or  it  may  appear 
abnormally  early,  even  in  early  childhood,  and  lead  to  masturbation 
or  perversity:  i.e.,  to  satisfaction  in  ways  contrary  to  nature  {comp. 
page  83). 

(li)  The  taint  often  betrays  itself,  finally,  in  neuropathic  condi- 
tions (neurasthenia,  hypochondria,  hysteria,  epilepsy),  which,  for  the 
most  part,  arise  at  the  time  of  pubert}^  and  progress,  presenting 
more  and  more  extreme  pictures  of  functional  degeneration. 

The  psychic  sphere  also  presents  analogous  manifestations  as 
the  expression  of  an  organic  taint,  of  a  psj^chopathic  constitution. 

In  the  emotional  life  the  remarkable  sensitiveness  and  irritabil- 
ity, and  the  ease  with  which  psychic  pain  and  affects  occur,  which 
may  reach  a  pathologic  degree  and  pass  on  into  complete  confusion, 
are  remarkable. 

In  many  individuals  of  this  kind  there  is  at  times  such  emotion- 
ality that  every  thought  leads  to  emotional  activity;  the  merest 
trifle  throws  them  into  extreme  emotional  excitement.  Slight  indis- 
positions, the  menses,  and  other  physiologic  events  may  have  this 


3G2  SPECIAL  "PATHOLOGY  AND  THERAPY  OF  INSANITY. 

effect.  Indeed,  even  mere  change  of  weather  may  cause  disturbance 
of  feeling,  either  directly  or  by  means  of  a  neuralgia.  Along  with 
this  remarkable  impressionability  and  enVotionality  there  is  not  infre- 
quently remarkable  dullness  of  sensibility.  Indeed,  there  may  be 
change  between  these  extremes  without  any  motive,  which  shows 
itself  in  peculiar  sympathies  and  antipathies.  In  a  large  number  of 
such  neuropsychopathic  persons  the  emotional  life  is  constantly  al- 
ternating between  exaltation  and  depression,  so  that  they  are  never 
indifferent  or  normal :   i.e.,  free  from  emotion. 

During  the  phases  of  exaltation  there  is  constant  tendency  to 
activity,  with  peculiar  and  even  dangerous  desires,  instincts,  and 
impulses.  In  the  depressive  periods  the  patient  suffers  with  painful 
indecision,  inability  to  act,  and  imperative  ideas,  especially  concern- 
ing suicide  and  fear  of  becoming  insane.  A  peculiar  anomaly  of 
feeling,  which  is  characteristic  of  an  entire  group  of  states  of  psychic 
degeneration,  is  the  complete  absence,  or  at  least  the  inexcitability, 
of  ethic  feeling. 

In  the  intellectual  domain  excitability  is  striking,  and  also  the 
unusual  power  of  imagination,  which  may  attain  the  degree  of  hal- 
lucination; likewise  the  rapidity  of  ideational  association  and  the 
inductive  manner  of  thought  are  remarkable ;  but  in  spite  of  this  ad- 
vantage, which  favors  artistic  and  scientific  activity,  the  irritable 
weakness  prevents  the  attainment  of  results.  Success  in  science  is 
prevented  by  rapid  exhaustion  and  the  consequent  incapability  of 
continued  intense  thought;  artistic  effort  is  hindered  by  the  defect  of 
intellectual  and  esthetic  endowment.  As  a  result  of  this,  the  artistic 
activities  of  such  individuals  take  on  curious,  even  monstrous,  or  at 
least  ugl}',  features.  At  the  same  time  tliere  is  frequently  a  remark- 
able defect  in  the  accuracy  of  reproduction  of  ideas.  The  process  of 
association  in  such  persons  is  remarkable.  It  seems  to  be  discon- 
nected. There  are  sudden  immediate  transitions  in  conversation. 
Clear  logical  thought  is  foreign  to  them.  Frequently  association 
takes  place  through  the  similarity  of  sound  and  words,  and  the  rela- 
tions are  so  widely  separated,  so  unusually  strange,  that  the  results  in 
thought  are  actually  astounding;  but  they  bring  on  fatigue  quickly. 
ISTot  infrequently  in  such  cases  there  are  imperative  ideas,  and  even 
desultory  anticipated  primordial  delusions,  wdiich  later,  with  the  on- 
coming of  paranoia,  reappear.  In  the  sphere  of  the  will  there  is  also 
great  mental  excitability,  with  slight  duration  of  excitement.  This 
results  in  enthusiasm,  w^hich  quickly  passes  off;  impulse  to  activity, 
which  never  brings  anything  to  an  end;  and,  as  a  result  of  this 
weakness  and  inconsequence  of  the  will,  the  individual  subject  to 


PSYCHIC  DEC  EN  ERAT  JONS.  363 

this  anomaly  seems  defective  in  character.  In  many  of  those  individ- 
uals,  especially  such  as  are  hereditarily  afflicted  with  abnormal  con- 
stitution, there  are  also  impulsive  acts.  Indeed,  oftentimes  these 
unfortunates  at  regularly  recurring  intervals  find  themselves  im- 
pelled to  repeat  the  same  perverse,,  eccentric,  or  even  immoral  act, 
without  being  conscious  of  any  impelling  motives.  Sometimes  it  is 
possible  to  discover  the  cause  of  such  acts — emotional  states,  idiosyn- 
crasies, or  imperative  ideas.  Any  attempt  at  synthetic  description 
of  such  an  abnormal  personality  meets  with  great  difficulties  on  ac- 
count of  the  variations  encountered  in  individuals. 

On  the  whole,  it  may  be  assumed  that  in  such  persons  the  uncon- 
scious sphere  of  mental  life  plays  a  more  important  role  than  in  nor- 
mal individuals.  Morel  very  properly  called  such  individuals,  in  so 
far  as  they  were  the  product  of  heredity,  instinctive  individuals. 
Their  imperative  ideas,  impulsive  acts,  and  peculiar  associations  of 
ideas  justify  this  conception. 

In  the  domain  of  the  higher  psychic  activities  the  lack  of  har- 
mony is  striking.  There  may  be  low  intelligence,  associated  with  a 
one-sided  remarkable  development,  even  in  idiots,  and  to  the  degree  of 
partial  genius;  weakness  of  will  and  of  character,  which  shows  itself 
in  defect  of  morality ;  incapability  of  an  ordered  life ;  and  resistless 
abandonment  to  immoral  inclinations,  with,  at  the  same  time,  per- 
versity and  one-sidedness  of  certain  kinds  of  thought  and  feeling 
which  causes  such  persons  to  appear  strange,  intense,  passionate,  and 
to  take  the  role  of  eccentrics,  misanthropes,  and  political  and  reli- 
gious enthusiasts.  Finally,  capricious  inclinations  and  antipathies; 
one-sidedness  of  certain  endowments;  inclinations  associated  with 
dullness  and  lack  of  interest  for  the  most  important  social  questions 
and  duties;  and  restless,  inconstant,  instinctive,  capricious  life  and 
acts,  form  the  most  frequent  and  striking  features  of  the  abnormal 
personality.  Frequently  enough  this  characteristic  is  shown  in 
peculiarities  of  conduct,  of  dress,  etc.  The  peculiarity  of  the  per- 
sonality is  also  frequently  shown  in  a  peculiar  neuropathic  expression 
of  the  eyes,  as  well  as  by  so-called  anatomic  signs  of  degeneration 
(comp,  page  129).  All  these  things  give  a  tangible  proof  that,  in 
their  earliest  periods  of  development,  injurious  influences  were  at 
work,  and  they  are  the  clear  expression  of  a  deviation  from  a  biologic 
type — a  degeneration.  Innumerable  tainted  individuals  remain  all 
their  lives  upon  the  borderline  between  pronounced  disease  and  rela- 
tive health,  at  least  for  the  individual.  Occasionally,  as  a  result  of 
psychic  or  somatic  influences,  they  lose  temporarily  their  relative 
psychic  equüibrium  and  present  abnormal  emotional  states,  patho- 


364  SPECIAL  PATIIOLOCV  AND  TIIERAPY  OF  INSANITY. 

logic  affects,  transitory  insanity,  etc.  If  tlicy  are  subjected  to  con- 
tinued or  frequently  repeated  strains,  they  become  victims  of  severe 
mental  disturbance,  which,  if  it  begin  in  early  years,  often  leads  to 
quick  termination  in  dementia.  In  any  event,  the  tendency  of  such 
tainted  individuals  to  become  insane  is  very  great.  Mere  changes  in 
the  manner  of  life,  of  the  place  of  residence,  misfortunes,  political 
and  social  movements,  are  frequently  sufficient  to  induce  such  a  re- 
sult. Even  the  physiologic  phases  of  life 'are  sufficient  to  induce 
insanity.  One  of  the  most  dangerous  periods  is  that  of  puberty.  Fre- 
quently the  pre-existing  psychic  anomalies,  the  eccentricities  and 
paradoxic  ideas,  impulses,  motives,  and  judgment  form  the  connect- 
ing link  between  psychopathic  predisposition  and  a  psycliosis,  in 
that  the  one-sidedness  or  weakness  of  the  intellectual  development, 
the  distortion  of  feelings  and  impulses,  constant  inclinations,  pas- 
sions, and  abnormalities  of  character,  form  the  favorable  foundation 
for  a  slight  exciting  cause  to  finally  induce  actual  insanity;  or  these 
peculiarities  themselves,  in  the  progressive  development  of  the  ab- 
normal predisposition,  may  lead  to  the  same  result.  Or,  again,  insan- 
ity develops  out  of  a  constitutional  neuropathic  state  (hysteria,  hypo- 
chondria, neurasthenia). 

In  general,  in  these  cases  the  prognosis  is  unfavorable. 

The  pathologic  anatomy  of  these  degenerations  is,  for  the  most  part,  un- 
investigated. The  substratum  of  psychic  degeneration  is  morphologically  un- 
known, and  this  notion  is  only  to  be  retained  in  a  functional  sense. 

HoweA-er,  the  significant  and  frequent  distiu'bance  or  deviations  in  the 
development  of  the  cranium  are  worthy  of  note.  Stahl  calls  attention  to  the 
interference  Avith  the  development  of  the  brain  due  to  distiu'bance  in  the 
growth  of  the  cranium  (microcephaly),  or  to  the  disturbed  development  de- 
jjendent  upon  infantUe  hydrocephalus  (macrocephaly).  Meynert  lays  stress 
upon  the  want  of  relation  between  the  brain  and  the  craniinn,  on  the  one 
hand,  and,  on  the  other,  the  development  of  the  heart  and  the  A'asciilar  system. 
Arndt  finds  -that  the  cerebral  convolutions  are  less  nimierous  and  not  so 
deeply  marked,  and  that  there  are  frequent  distortions  of  parts  of  the  brain, 
especially  of  the  occipital  lobes,  and  a  consequent  shortness  of  the  posterior 
horn  of  the  lateral  ventricle. 

Other  findings  of  Arndt  are  also  remarkable:  in  originally  neuropathic 
individuals  many  cortical  cells,  even  in  the  adult  brain,  remain  at  an  embryonic 
stage,  and  the  development  of  the  medullar}-  sheath  of  the  axis-cylinders  re- 
mains incomplete,  with,  besides,  incompleteness  of  development  of  the  lym- 
phatics and  vessels,  associated  with  constitutional  anemia.  The  acquired 
degeneration  may  be,  in  part,  referred  to  disturbances  in  the  nutrition  of  the 
vascular  walls  and  to  disturbances  of  vasomotor  innervation,  such  as  occiu'  in 
severe  diseases,  chlorosis,  alcoholism,  sexual  excesses,  senility,  etc. 


rsY(jiJj(j  I)K<;I';nki;atiuns.  3G5 


CHAPTER  IF. 


Constitutional  Affective   Insanity   (holie  Raisonnante). 

It  occurs  in  two  forms:  a  maniacal  and  a  melancholic.  While 
the  first  takes  almost  exclusively  the  form  of  recurring  attacks, 
and  is  described  under  tlie  lieading  of  periodic  mania,  the  latter,  since 
it  runs  a  continued  course,  is  here  to  he  described  as' melancholic  folie 
raisonnante.  The  reasoning  character  of  the  disease-pjcture  was 
mentioned  as  a  symptom,  but  not  as  a  form  of  disease,  in  the  section 
on  "General  Pathology/'  The  degenerate  character  of  this  symp- 
tom was  noted  in  a  clinico-symptomatologic  description  of  states 
of  psychic  degeneration,  and  the  fact  was  emphasized  that  certain 
patients  present  a  wonderful  mixture  of  lucidity  and  disease,  know 
well  how  to  excuse  perverse  acts,  are  perverted  in  action  and  feeling, 
hut  formally  think  correctly  and  logically.  Delusions  and  errors  of 
the  senses  are  wanting,  or  occur  only  episodically  from  some  peculiar 
transitory  cause,  as  in  emotional  excitement.  They  remain  elemen- 
tary symptoms.  Along  with  the  reasoning  must  he  emphasized  the 
stationary,  non-progressive  character  of  the  disease-picture,  in  spite 
of  its  existing  years  or  all  the  patienf  s  life.  It  has  for  this  reason 
a  profound  constitutional  significance. 

Melancholic  Folie  Kaisonn-ante. 

This  disease  occurs  most  frecjuently  in  females.  Hereditary  taint 
is  probably  the  predisposing  cause.  As  a  rule,  for  years  the  symptoms 
of  a  constitutional  neurosis,  like  neurasthenia  or  hysteria,  precede 
the  psychosis  and  accompany  it  in  its  further  course.  Affections  of 
the  uterus,  especially  infarcts  and  abnormalities  of  position,  are 
shown  to  be  important  exciting  causes  in  the  development  of  the  psy- 
chosis. Where  there  is  hereditary  taint  the  malady  may  develop 
without  any  accidental  cause.  Under  such  circumstances  it  occurs 
before  puberty  or  at  that  time,  -and  then  remains  constitutional. 

By  physicians  that  are  not  specialists  the  fundamental  neurosis 
alone  is  usually  diagnosticated,  and  the  psychic  element  of  the  dis- 
ease-picture is  not  recognized.  In  social  life  the  condition,  as  a  rule, 
is  judged  merely  from  an  ethic  standpoint,  and  the  patient  looked 
upon  as  of  disagreeable  character  or  moody.  Falret  has  described  the 
disease  in  its  principal  features  as  "moral  hypochondria  with  con- 
sciousness of  the  condition." 

Clinically  there  is  habitually  disagreeable  moodiness,  a  constant 
state  of  depression  which  shows  itself  in  irritability,  dissatisfaction. 


3GG  SPECIAL  PATHOLOGY  AND  TTTERAPY  OF  INSANITY. 

a  tendency  to  quarrel  and  speak  evil,  and  inclination  to  maltrout 
others.  The  mind  of  such  patients — Avho  i'roqucntly  enough  are 
taken  for  cross,  qnarrelsome  Avomen;  jealoTis  wives;  heartless,  cruel 
in(ithors — is  constantly  umk-r  (lie  constraint  of  painful  feeling.  They 
liavc  a  constant  painful  reproduction,  and  their  psychic  dysesthesia 
<\nd  anostliesia  give  theui  only  unpleasant  impressions  from  the  ex- 
ternal world.  They  sec  only  the  dark  side  of  life,  with  everything 
black  and  threatening,  and  only  unpleasant  impressions  are  experi- 
enced; even  the  slightest  unpleasant  circumstance  renders  their  con- 
dition decidedly  worse.  They  are  abulic,  without  feeling,  without 
pleasure,  incapable  of  continued  work  and  intellectual  application, 
unhappy,  and  in  despair,  even  to  tcedium  vitce.  They  suffer  con- 
stantly with  the  oppression  of  their  abnormal  feelings  and  physical 
troubles,  and  are  given  to  a  continued  reproduction  of  them.  In  such 
cases  imperative  ideas  are  frequent.  As  proof  of  the  abnormal  nature 
of  the  character,  Avhich  apparently  is  simply  disagreeable,  there  are : 
the  course  with  its  exacerbations  and  remissions;  the  intensification 
of  the  symptoms  at  the  time  of  menstruation;  the  complaint  of  the 
patients,  during  periods  of  comparative  freedom,  that  they  act  in 
opposition  to  their  better  conscience  and  will,  in  that  they  are  forced 
to  be  mean  and  try  to  injure  others.  There  are  also  occasional  attacks 
of  anxiety  observed  during  affects;  delusions  of  persecution;  and 
finally  the  accompan3'ing  neuropathic  symptom-complex  (neuras- 
thenia, spinal  irritation,  hysteria),  with  the  paroxysms  of  disagreeable 
moods  and  irritability.  Not  infrequently  such  patients  are  constantly 
afraid  of  becoming  insane.  By  way  of  therapy,  besides  the  treatment 
of  the  neurotic  symptoms  and  the  very  frequent  uterine  disorders, 
hydrotherapy  is  to  be  recommended  (lukewarm  baths,  rubbings  with 
wet  shegts),  and  also  morphine  hypodermically,  which,  of  course, 
has  only  a  palliative  effect;  but  at  the  time  of  exacerbations  it  re- 
duces the  moral  and  physical  suffering  of  such  patients  to  a  minimum. 
The  danger  of  creating  the  morphine  habit  is  to  be  very  care- 
fully considered. 

Case  21. — Melancholic  folie  raisoniiante.  Interesting  descrip- 
tion of  the  condition  by  the  patient. 

J.  D.,  aged  40,  comes  of  a  very  tainted  family.  Father's  sister  had  nerv- 
ous attacks;  father  was  a  trembler  and  became  disagreeable  and  choleric. 
Father's  brother  and  father's  father  were  insane.  Four  of  her  brothers  and 
sisters  are  nervous,  and  occasionally  are  mentally  disturbed.  The  patient's 
life  was  poisoned  at  its  very  beginning.  As  a  child  she  was  emotional,  often 
sad  and  depressed  without  cause.  With  the  occurrence  of  the  menses  in  her 
sixteenth    year    there    was    hysteria,    which    developed    into    hystero-epilepsy 


rSYCHIC  DEGENERATIONS.  3ß7 

(clonic  co-ordinated  convulsions,  with  unconsciousness).  At  llie  n'^c  of  22 
these  attacks  disappeared.  The  patient  remained  neuropatliic  (vague  neu- 
ralgias, feelings  of  chilliness,  globus) ;  gradually  this  neurosis  developed  into 
the  psychosis,  which  continues  unchanged  at  the  jjrcscnt  time,  only  varying 
in  remissions  and  exacerbations. 

The  fundamental  features  of  this  malady  are  a  profound  psychic  depres- 
sion, a  constant  psychic  pain,  and  a  painful  state  of  emotional  inhibition. 

Parallel  with  this  psychic  hyperesthesia  and  dysesthesia  there  are  vague 
neuralgic  complaints  in  the  spinal  paths,  nervou.sness,  and  a  condition  of 
nervous  unrest.  The  psychic  dysesthesia  expresses  itself  in  that  the  whole 
external  world  appears  to  her  troubled,  painful,  and  repulsive.  Even  friendly 
benevolent  activity  is  painful  to  her.  Often  against  her  own  will  she  is  forced 
to  be  hostile  and  disagi'eeable  to  those  around  her,  even  toward  her  very  best 
friends.  At  the  same  time,  there  is  pronounced  psychic  anesthesia.  She  is 
without  pleasure.  Life  has  no  allurement  for  her,  but  is  a  burden  from  which 
death  would  be  a  welcome  deliverance.  The  intellect  is  only  formally  dis- 
turbed. The  patient  has  no  delusion,  and  she  is  at  the  same  time  fully  con- 
scious of  her  disease.  The  knowledge  that  she  must  be  so  opposed  to  every- 
thing that  other  persons  love  and  prize  increases  her  pain.  Her  thought  is 
quite  dependent  upon  her  abnormal  feelings.  She  is  constantly  tormented  by 
sad,  painful  thoughts.  In  the  domain  of  the  Avill  the  patient  is  without  in- 
terest and  her  life  is  one  of  dull  resignation  and  retirement.  At  times  the 
disease-picture  changes.  She  becomes  restless,  irritated,  reacts  in  a  hostile 
way  toAvard  the  external  world,  and  asks  deliverance  and  death.  The  rest- 
lessness expresses  itself  in  all  kinds  of  impulsive,  purposeless  acts.  The  hostile 
destructive  acts  are  a  pure  psychic  reflex  action,  analogous  to  convulsions  due 
to  spinal  reflexes  which  a  neuralgia  might  cause.  They  take  place  beneath  the 
threshold  of  consciousness,  and  the  patient  i^  unable  to  control  them.  They 
are  induced  partly  by  the  multitude  of  painful  feelings  of  psychic  dysesthesia 
and  anesthesia,  comparable  to  exacerbations  of  a  neuralgia;  partly  by  pre- 
cordial distress  and  imperative  burdensome  ideas,  in  which  the  painful  feeling 
renders  itself,  for  the  moment,  objective.  Such  paroxysms  occur  in  attacks. 
With  this  psychic  hyperesthesia  expressing  itself  reflexiv,  there  are  analogous 
spinal  hyperesthesia,  vague  neuralgic  pains,  troublesome  gnawings  and  sensa- 
tions in  the  extrenüties.  Sleep  is  restless  and  disturbed  by  frightful  dreams. 
Habitual  constipation  and  constitutional  anemia  complete  the  disease-picture. 
The  only  treatment  that  has  done  good  is  injections  of  morphine.  These  have 
only  a  palliative  efl'ect,  but  under  their  influence  there  is  a  state  of  relative 
well-being  for  which  the  patient  cannot  express  her  gratitude.  Better  than 
any  clinical  analysis  of  this  state  of  melancholia  Avithout  delusion  is  the  fol- 
lowing letter  from  the  patient,  which  includes  the  essentials: — 

"Pardon  me  for  my  great  Avillingness  to  respond  to  your  desire,  for  I  am 
quite  unable  to  explain  myself  by  word  of  mouth.  My  thoughts  come  in  bat- 
talions; they  are  my  tyrants,  and  I  am  constantly  forced  to  think.  Pica- 
sonable  thoughts  are  constantly  overcome  by  CAdl  thoughts.  Tlie  evil  thoughts 
are  so  poAverful,  so  numerous,  A'aried,  and  inconstant,  that  they  change  every 
quarter  of  an  hour  of  the  day  for  months  and  years,  and  these  cause  an  equal 
number  of  projects  AA'hich  I  am  forced  in  fear  to  carry  out  on  the  instant.  For 
example,  I  Avill  and  must  die,  be  droAvned,  or  suffocated  by  charcoal-gas.  This 
^nd  similar  thoughts  oppress  me  without  cessation,  though  AA'hen  the  frightful 


3GS  SPECIAT.  PATIIOI.OCV  .\\11    111  KU  A  I'V   (»K   INSAMTV. 

nioiiient  is  passed,  1  am  abU-  with  j^real  etlort  to  ovtMconie  the  iiiipulsc.  Twice 
I  luive  been  c-onquered,  but  fuitunatvly  or  iinfmtuiiatoly  I  was  saved.  I  was 
once  frightfully  forced  by  a  thouylitless  person  to  drink  llu-  water  of  a  dying 
patient  siiflerinfr  from  nervous  fever,  because  1  thought  that  ileatli  wouUl  be 
certain;  but  it  was  in  \ain.  At  the  time  of  the  menses  1  liuve  sat  in  eohl 
spring-water,  etc..  l)ut  without  the  desired  result.  1  have  frightful  fear  tlial  I 
shall  live  very  long,  and  for  this  reason  1  wish  that  you  could  give  nie  souio 
fatal  (hug. 

"Were  my  life  to  become  more  bearalile.  were  I  to  die.  I  should  he  tiiank- 
ful  to  you  forever;  for  my  variations  oi  sutVering  are  such  that  i  can  never 
express  them.  The  sun,  pleasant  companions,  and  distractions  are  torment  to 
me.  Storm,  tempest,  earthquake,  darkness,  tires  would  be  my  greatest 
pleasure  if  they  were  not  always  temporary.  1  was  never  hajjpier  than  during 
the  bombardment  (Strassburg).  I  cared  for  tlie  sick  and  wounded  with  per- 
fect content  and  devotion;  but  this  Avas  also  in  vain.  Of  late  I  have  the  most 
terrible  thoughts.  It  is  true  that  I  can  speak  reasonably,  but  I  cannot  think 
reasonably:  and  externally,  for  the  most  part,  no  one  would  notice  it.  I  feel 
almost  always  driven  to  commit  some  act,  I  know  not  what.  I  am  never  quiet, 
but  I  never  know  why.  For  the  most  part,  I  cannot  sleep  at  night,  and  have 
anxious,  despairing  dreams,  and  I  strike  about  me  while  sleeping.  I  am  very 
much  inclined  to  strike  and  much  inclined  to  anger  and  impatience.  Fre- 
quently I  am  inclined  to  insult  persons,  even  those  much  respected  by  me,  and 
treat  them  with  disdain;  and  often  I  am  impelled  to  sudden  jumping,  when  I 
cannot  restrain  mj'self.  After  that  I  am  tired  and  frightfulh^  depressed  and 
cannot  move.  Too,  during  the  day.  I  am  overcome  with  depressive  sleep, 
forced  to  sleep,  but  cannot  sleep  long,  and  afterward  the  torture  is  still  worse; 
but  I  know  not  why.  Then,  in  the  intervals  I  often  feel  physical  distress,  dif- 
ferent symptoms  of  excitation  in  my  limbs,  which,  however,  are  never  like  the 
other  forms  of  inner  distress.  Now,  however.  I  haA'e  much  hope  that  the 
injections  of  morphine  A\liich  do  me  good  Avill  diminish  the  duration  of  the 
frightful  periods.  I  beg  for  them  only  in  time  of  greatest  need,  and  I  shall 
never  misuse  their  benefit." 


CHAPTER  III. 
Paranoia. 


This  term^  is  ap]ilied  to  a  chronic  mental  disease  occurring  ex- 
clusively in  tainted  individuals,  frequently  developing  out  of  the  con- 
stitutional neuroses,  the  principal  symptoms  of  which  are  delusions. 

In  contrast  with  those  of  melancholia  and  mania,  the  delusions 
in  this  disease,  devoid  of  all  emotional  foundation,  are  primary  crea- 
tions of  the  ahnormal  hrain,  and,  in  contrast  Avith  the  delusions  of 
primary  hallucinatory  insanity,  are,  from  the  beginning,  S3^steniatized, 


^Synonyms:  primäre  Verrücktheit  (Griesinger)  ;  delire  ])artiel ;  delire 
systematise-;  folic  systematisee  (^lorel)  ;  monomanie  intcllectuelle  (Ksquirol); 
paranoia  universalis   (Arndt);    chronischer  A\'alinsiim   (ISchüle). 


PSYCHIC  DEGENERATIONS.  369 

methodic,  and  combined  by  the  process  of  judgment,  constituting  a 
formal  delusional  structure.  This  ca^jability  of  combining  and  rea- 
soning activity,  in  contrast  with  the  psychic  processes  in  primary 
hallucinatory  iiisanit}^,  is  possible  owing  to  the  relative  freedom  from 
damage  of  the  intellect,  at  least  on  its  formal  side  (judgment);  so 
tliat  on  superficial  observation  one  is  struck  by  the  clearness  and  logic 
of  such  patients  (monomania). 

Notwithstanding  the  apparent  lucidity  of  consciousness,  this  is, 
however,  disturbed  in  a  peculiar  way,  in  that,  in  spite  of  the  absence 
of  emotion,  in  spite  of  the  clearness  of  apperception,  the  patient 
cannot  correct  his  imagination,  hallucinations,  etc.,  and  rather — 
devoid  of  the  power  of  criticism — accepts  them  as  facts.  Thus  his 
judgments  are  necessarily  based  upon  false  premises,  and  the  crea- 
tion of  delusional  conceptions  is  the  necessary  result,  the  foundation 
and  keystone  of  which,  notwithstanding  the  correctness  of  the  logical 
creation,  are  fictions. 

The  feelings  and  acts  of  the  patient  are  reactive  manifestations 
to  delusions  and  hallucinations. 

Thus  the  important  point  of  the  disease  does  not  lie,  like  in 
melancholia  and  mania,  in  primary  emotional  and  psychomotor  dis- 
turbances, but  in  the  disturbances  of  the  ideational  sphere  (delusions 
and  absence  of  critical  power).  The  paranoiac  feels  and  acts  exactly 
as  if  his  delusion  were  tr^ie.  The  development  and  course  of  paranoia 
are  always  chronic.  The  development  is  slow,  through  months  or 
years  of  a  stage  of  incubation,  until  its  height  is  reached.  It  then 
remains  years  and  decades  stationary,  but  never,  as  in  the  case  of  in- 
curable psychoneuroses,  ends  in  dementia.  Eecovery  I  have  never 
seen  in  the  observation  of  more  than  a  thousand  cases,  though,  how- 
ever, I  have  seen  lucid  intervals,  especially  in  the  beginning  of  the 
disease,  of  ephemeral  duration;  and  also  profound  and  continued  re- 
missions with  complete  latency  of  the  symptoms  (delusions  and  hallu- 
cinations). 

Complete  intermissions,  with  insight  and  correction  of  delusions 
lasting  even  many  months,  are  not  infrequent.  Such  intermissions 
may  occur  even  after  years,  but  they  must  not  be  confounded  with 
recovery;  for  in  all  these  cases,  after  a  longer  or  shorter  time,  the 
paranoia  reappears,  not  as  a  relapse  in  which  the  whole  disease  cycle 
is  reproduced,  but  as  a  continuation  from  the  point  where  it  left 
off.  Furthermore,  the  frequent  and  sometimes  very  skillful  dis- 
simulation of  these  patients  is  not  to  be  confounded  with  an  inter- 
mission. Under  some  circumstances  they  are  able  to  control  them- 
selves and  appear  to  be  well,  and  it  is  only  in  emotional  excitement 


370  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

that  they  betray  themselves  and  reveal  further  elements  of  their 
painful  or  heroic  history. 

•Study  of  the  manner  of  origin  of  the  pi-iiu'ipal  symptoms  of  this 
disease,  which  consists  essentially  in  mental  disturbance  in  the  form 
of  delusions,  is  of  the  greatest  importance  for  an  understanding  of 
it.  In  the  beginning  the  elements  of  delusions  develop  out  of 
imagination  and  defective  judgment,  aided  by  the  remarkable  orig- 
inal defect  of  logic;  and,  further,  out  of  illusions  of  memor}',  and 
occasionally  even  out  of  actual  errors  of  memory. 

At  this  period  primordial  abnormal  creations  in  thought  may 
appear  episodically.  Upon  the  patient  they  have  the  same  effect  as 
imperative  ideas:  trouble  him,  make  him  apprehensive,  depress  him. 
But  they  do  not  long  resist  the  relatively  intact  reason  and  judgment 
of  the  patient.  In  the  further  course  to  the  height  of  the  disease, 
actual  illusions  of  the  senses,  which  favor  the  development  of  de- 
lusions, are  added. 

The  beginning  of  the  height  of  the  disease  is  indicated  by  hal- 
lucinations, which  the  fully  developed  paranoiac  consciousness  (dis- 
appearance of  critical  power,  etc.),  for  the  most  part,  uses  without 
hindrance  for  the  development  of  delusions.  At  the  height  of  the 
disease  the  delusions  develop  essentially  in  the  way  described.  Their 
most  important  source,  however,  lies  in  direct  genesis,  as  an  expres- 
sion of  spontaneous  abnormal  functioning  of  the  cerebral  cortex, 
upon  which  thought  depends  (primordial  delusions),  as  well  as  in  hal- 
lucinations. There  are  a  few  cases  in  which  at  the  height  of  the 
malady  the  develojDment  of  delusions  is  essentially  primordially  idea- 
tional ("paranoia  combinatoria") ;  but  cases  are  more  frequent  in 
which,  during  the  origin  and  course  of  the  disease,  the  sensorial  hal- 
lucinatory domain  is  almost  exclusively  implicated  ("paranoia  hallu- 
cinatoria"). 

Indirectly,  by  means  of  reflection  and  conscious  elaboration, 
every  element  may  undergo  infinite  extension  and  application  in  the 
sense  of  secondary  delusions.  With  the  complete  unfolding  of  the 
effect  of  the  paranoiac  consciousness  there  is  the  material  which 
paramnesias  (the  confounding  of  delirious  or  dream-pictures  with 
actual  facts),  illusions  of  memory,  and  actual  errors  of  memory  afford. 
Innumerable  elements  are  finally  off'ered  by  the  pre-existing  constitu- 
tional neuroses:  the  numerous  disturbances  of  sensibility,  motility, 
etc.,  which  the  paranoiac  consciousness  no  longer  refers  to  physical 
disease,  but  to  influences  from  the  external  world. 

At  the  height  of  disease  this  transformation  of  anomalies  of  the 
senses  into  delusional  ideas  takes  place  easily  and  imperatively;  and, 


PSYCHIC  DEGENERATIONS.  371 

on  the  other  hand,  the  liyjjorcstlicsia  of  the  centers  and  conducting 
paths  makes  possible  the  immediate  transforraatioii  of  ideas  into 
sensations. 

Thus  the  patient  lives  in  a  world  of  error  and  deception;  and, 
unfortunately,  his  logical  powers,  acting  correctly,  create  an  entii'c 
system  of  delusions. 

The  degenerate  signiflcancc  of  the  discasc-|)icturo,  which  Morel 
clearly  recognized,  has  been  of  late  re])('atedly  called  in  question 
(Mendel  and  others),  and  paranoia  has  been  regarded  as  a  chronic 
form  of  acute  hallucinatory  insanity. 

I  have  never  seen  paranoia  in  untainted  persons.  The  taint,  in 
the  vast  majority  of  cases,  has  been  hereditary  (abnormal  character, 
psychoses,  constitutional  neuroses,  drunkenness  in  ancestry);  less  fre- 
quently acquired  as  result  of  infantile  diseases  of  the  brain,  or  of 
rickets  or  disturbances  of  development  of  the  cranium  and.  brain. 
Tanzi  and  Eiva  found,  in  their  cases  of  paranoia,  heredity  in  77  per 
cent.,  and  in  9.5  per  cent,  disturbances  of  development  due.  to  infan- 
tile cerebral  disease.  In  the  remaining  14  per  cent,  hereditary  ele- 
ments could  not  be  demonstrated,  nor  could  they  be  excluded. 

For  the  scientific  solution  of  the  question  the  clinical  proof 
of  taint  in  the  individual  case  is  much  more  important.  In  this  sense, 
careful  examination  of  the  j)re-existing  morbid  conditions  and  the 
present  personality  will  never  give  a  negative  result. 

Such  an  examination  will  alwa3^s  show  that  the  whole  develop- 
ment of  the  character  of  these  candidates  for  paranoia  is  abnormal, 
and  it  cannot  be  denied  that  frequently  the  special  direction  of  the 
anomaly  of  character  determines  the  special  form  of  the  later  de- 
veloped paranoia;  so  that  the  latter  represents,  as  it  were,  an  hyper- 
trophy of  abnormal  character.  Thus,  for  example,  an  originally 
suspicious,  retiring,  solitary  individual  one  day  becomes  persecuted; 
a  rough,  irritable,  egotistic  person,  defective  in  his  notions  of  justice, 
becomes  a  querulous  paranoiac;  a  religious  eccentric  becomes  the 
victim  of  religious  paranoia. 

The  development  of  the  disease  out  of  the  central  nucleus  of 
the  personality — the  character — throws  important  light  upon  a  fact 
which  later  makes  its  appearance  in  the  disease;  namely,  upon 
the  predominant  role  that  the  unconscious  mental  life  plays  in  such 
cases,  as  compared  with  that  of  the  conscious  life.  Indeed,  the  char- 
acter is  essentially  the  expression  of  the  power  of  unconscious  mental 
activity.  Its  predominance  is  shown  in  the  dreamy,  romantic,  en- 
thusiastic life  of  such  individuals,  and  in  the  fact  that  accidental 
delusions  occurring  in  sickness,  dream-pictures,  and  reminiscences 


372  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

from  reading  or  from  plays,  are  elaborated  in  the  depth  of  the  soul, 
and  early  burst  forth  in  the  form  of  imperative  ideas  and  desultory 
primordial  delusions,  which  become  latent,  but  later  find  their  ulti- 
mate evaluation  in  the  delusional  ideas  of  the  disease.  As  a  rule,  the 
imaginative  activity  of  these  individuals  is  very  lively  and  easily 
excited.  The  intellectual  endowment  may  be  fair,  but  it  is  often 
one-sided. 

The  unresisted  predominance  over  the  ego  by  the  creations  of 
the  disease  (delusions,  hallucinations),  in  spite  of  the  absence  of 
emotional  disturbance;  the  unrestrained  abandonment  to  them  with- 
out sense  or  control,  with  their  astoundingly  rapid  development  into  a 
system  of  delusions;  and  still  more  the  illogical,  perverted  ideational 
association — all  these  point  to  an  abnormally  organized  brain.  This 
is  shown  with  especial  clearness  by  the  constant  inclination  of  those 
patients  to  bring  into  relation  with  their  own  personality  the  events 
in  the  external  world. ^ 

Quite  unsought,  devoid  of  all  reflection,  with  an  original  per- 
versity of  logic,  even  though  it  be  correct,  these  relations  arise,  and 
in  consciousness  they  have  immediately  the  significance  of  unassail- 
able facts.  Even  senseless  accidental  words  -  make  deep  impressions 
and  are  understood  in  the  strangest  way— incomprehensible  to  a  nor- 
mal brain — and  are  brought  into  relation  with  the  personality  in  a 
l^erverted  and  symbolic  manner. 

The  patliologic-o-anatoniic  findings  in  this  form  of  insanity  affecting  the 
innermost  nucleus  of  the  personality,  and  having  its  root  in  the  character 
itself,  are  still  very  equivocal.  Frequently  there  are  asymmetries  in  the  devel- 
opment of  the  carotid  and  vertebral  arteries,  of  the  cranium,  of  the  hemi- 
spheres of  the  cerebrum, — and  these  findings  are  certainly  not  without  relation 
to   the   character;     but,   as   an   explanation   of   the   real   disease-process,   the 


^  One  of  my  patients  read  the  advertisement  of  a  midwife  in  a  newspaper, 
and  immediately  brought  it  into  relation  with  herself,  thinking  that  she  was 
thought  to  be  pregnant.  Another  inserted  a  love  advertisement  in  a  journal. 
The  next  day  when  she  read  at  the  corner  of  the  street  an  advertisement  of 
the  well-known  play  called  "Sie  ist  Wahnsinnig"  ("She  is  Crazy"),  she 
thought  it  referred  to  her.  A  patient,  from  the  croaking  of  the  frogs  in  the 
water,  thought  that  he  heard  indications  that  he  should  leave  the  place  where 
he  was  living  and  which  was  unpleasant  to  him.  Another,  a  female  patient, 
took  the  announcement  of  the  play  called  "The  Newly  Married"  as  an  insult- 
ing allusion  to  a  love-affair  of  twenty  years  before. 

-  One  of  my  patients  went  to  Calvarienberg  (a  churcli  of  pilgrimage  in 
Gratz).  Immediately  he  interpreted  the  word  in  the  following  manner: 
Cal  =  Calle  (bride) ;  van'  ^=  war  (was)  ;  i  =:  Ignaz  (the  name  of  his  youngest 
brother)  ;  en  is  the  sign  for  Russia,  and  leads  to  great  complications  in  the 
patient's  thoughts. 


PSYCHIC  DEGENERATIONS.  373 

autopsies  are,  for  the  most  part,  of  negative  significanpe.  The  absence  of 
gross  anatomic  changes  may  also  explain  the  fact  that  the  disease  does  not 
progress  to  dementia,  or  at  least  leaves  the  formal  mechanism  of  judgineiit 
unimpaired. 

The  exciting  causes  of  the  outbretik  of  the  disease  are  those 
usual  in  insanity  in  general;  1nit  puberty,  the  climacteric,  uterine  dis- 
ease, and  onanism  seem  especially  important. 

The  development  of  the  disease  is  ordinarily  gradual,  growing, 
so  to  speak,  out  of  the  abnormal  personality,  thus,  as  a  rule,  es- 
caping observation. 

The  stage  of  incubation  is  that  of  presumptions  and  suppositions, 
in  contrast  with  the  developed  disease,  in  which  delusions  and  hallu- 
cinations become  certainty.  In  this  initial  stage,  to  the  correct  per- 
ceptions of  the  external  world  are  added  impressions  dependent  upon 
the  character  of  the  patient  and  arising  out  of  his  unconscious  mental 
life,  which  are  immediately  associated  with  his  perceptions.  Some- 
thing behind  the  phenomena  is  noticed  and  sought  which  does  not 
belong  to  them  (Hagen).  Since  the  patient  is  not  conscioits  of  the 
source  of  these  ideas,  the  peculiar  relation  of  his  perceptions  seems 
to  him  to  be  a  fact;  and,  since  all  that  arises  in  his  perception  has 
its  origin  in  himself,  all  is  brought  into  relation  with  himself.  Actu- 
ally this  distortion  is  no  illusion,  but  temporarily  it  may  become  such. 
Any  emotional  astonishment  or  enthusiasm  is  not  primary,  but  sec- 
ondary. At  times  logic  may  correct  these  dreams,  but  ahvays  the 
intellectual  error  reasserts  itself.  The  intensity  of  imagination  and 
attention  favors  this.  Accidental  occurrences  intensify  the  suspi- 
cion. In  such  cases  erroneous  conceptions  of  the  external  world  re- 
sulting from  reflection  and  illusion,  such  as  occur  in  melancholic  and 
maniacal  patients  due  to  abnormal  emotional  conditions,  do  not  exist; 
but  there  is  an  unconscious,  organic  foundation  for  that  which  seems 
to  come  only  from  the  external  world.  Thus,  the  latter,  like  the 
thoughts  of  the  patient,  appears  to  be  of  a  peculiar  nature.  The 
unconscious  mental  activity  further  develops  these  thoughts,  and 
causes  mere  suppositions  to  ripen  into  primordial  delusions. 

The  transition  to  the  stage  of  full  development,  characterized 
by  the  formation  of  delusions,  is  rarely  sudden,  with  stormy  mani- 
festations (anxiety,  convulsive  attacks,  hallucinations  occurring  and 
developing  into  true  hallucinatory  delirium),  but  usually  gradual; 
in  that  the  unconscious  presumptions  develop  into  illusory  percep- 
tions, until  finally  an  astounding,  though  accidental,  event  changes 
in  an  instant  the  supposition  to  certainty ;  and  with  the  accompanying 
emotion  the  delusion  enters  consciousness.    With  this,  judgment  and 


3:4  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

reason  are  lost.  Everything,  accordingly,  lias  either  a  hostile  or  a 
favorable  relation  to  the  subject. 

An  iincolored  perception  is  now  scarcely  possible.  Xow,  there 
is  temporarily  delirium  of  general  transformation.  Everything  is 
changed,  imitated,  etc.  (deliriimi  nictüholicuiii — ]\Jen(K'l). 

'J'he  manner  of  origin  oL  llu'  delusions  that  now  pi'tHloniinate 
is  ])artly  found  in  direct  excitation  of  ideational  centers  and  partly 
in  organic  pci'ijjheral  excitation,  which,  without  entering  clearly  into 
consciousness,  still  excites  consciousness,  or  the  psychosensorial  cen- 
ters, and  thus  induces  corresponding  delirious  ideas  (sexual,  hy])oehon- 
driae)  or  hall ueiiuit ions.  In  the  mechanism  of  his  unconscious  mental 
lit'e  the  patient  is  not  conscious  of  these  processes,  and  arrives  at  the 
result  by  a  detour  through  hallucinations  and  primordial  delusions. 

At  first  these  creations  have  an  astounding  effect;  but  the  pa- 
tient assimilates  them  quickly.  They  have  the  same  remarkably  over- 
powering effect  upon  him  as  they  would  have  were  they  unquestion- 
ably true.  The  motive  appears  late  or  not  at  all.  The  patient  defeiids 
that  which  he  believes  to  be  a  fact.  Not  infrequently  the  first  pri- 
inordial  delusions  take  their  origin  in  the  formal  activity  of  the 
dreamy  conditions  of  waking  dreams  and  delirium;  just  as  earlier 
dream-pictures  and  delirium  may  undergo  reproduction  and  thus 
become  mentally  actual.  This  origin  explains  in  part  the  strange 
allegoric  and  romantic  content  of  the  delusions.  (Vide  "  Original 
Paranoia  "  and  "  Hysteric  Paranoia.") 

Tiie  most  important  source  for  the  origin  and  further  develop- 
ment of  delusions  lies,  however,  in  the  hallucinations,  which  are 
rarely  wanting  at  the  height  of  the  disease.  The  ideational  source  of 
these,  likcAvise,  lies  in  the  subconscious  mental  sphere,  and  the  hal- 
lucinations are,  as  far  as  consciousness  is  concerned,  quite  as  foreign, 
astounding,  and  incomprehensible  as  are,  in  the  beginning,  the  pri- 
mordial delusions.  In  later  periods  of  the  disease  conscious  thought 
may  also  be  transformed  into  voices. 

In  harmony  with  Samt,  I  find  hallucinations  of  heai'ing  most 
fi-ecjuent  and  inqwrtant,  and,  thereafter,  in  order,  errors  of  sensi- 
bility, vision,  taste,  and  smell. 

In  spite  of  all  individual  peculiarities,  especial  interest  lies  in 
the  content  of  the  primordial  delusions,  which  is  essentially  the  same 
in  all  patients. 

The  delusions  in  content  are  concerned  either  with  ideas  of 
injurv  or  of  furthering  of  the  vital  relations  of  the  patient  (delusions 
of  persecution  and  grandeur).  Much  more  frequent  than  grand  de- 
lusions are  those  of  persecution.     Both  may  occur,  one  after  the 


PSYCHIC  DEGENERATIONS.  375 

other,  or  together,  in  the  same  disease-picture;  or  one  may  exist 
alone.  Where  the  delusion  hegins  as  an  idea  of  persecution,  not 
infrequently  in  the  later  course  of  the  disease,  ideas  of  grandeur 
become  so  powerful  and  numerous  that  they  quite  overcome  the 
delusion  of  persecution.  The  persecuted  person  becomes  a  distin- 
guished personality  (transformation),  and  then  both  series  of  delu- 
sions are  brought  necessarily  into  relation;  and,  even  though  those 
secondarily  developed  are  predominant,  yet  those  that  were  primary, 
in  the  further  course  of  the  disease,,  still  make  their  appearance  now 
and  then. 

As  indications  of  future  transformation  there  are  early  abrupt 
primordial  delusions  of  grandeur,  with  corresponding  hallucinations, 
which  disappear  quickly  for  the  time  being. 

When  paranoia  commences  with  predominating  delusions  of 
grandeur  and  runs  its  course,  no  transformation  occurs,  though  there 
may  be  episodically  and  occasionally  primordial  delusions  of  persecu- 
tion. As  reactive  secondary  manifestations,  there  are  violent  emo- 
tional states,  Avhich,  in  accordance  with  the  content  of  the  delusions, 
take  the  form  of  fear,  outbursts  of  despair,  or  emotional  feelings  of 
inspiration  which  may  reach  the  degree  of  ecstasy.  The  first  may  be 
accompanied  by  precordial  sensations.  Sometimes  there  are  spon- 
taneous outbreaks  of  fear,  organically  caused,  which  may  take  the 
form  of  raptus-like  outbursts. 

The  malady,  the  course  of  which  is  in  general  chronic,  often 
develops  with  apparent  rapidity,  owing  to  sudden  increase  of  inten- 
sity (Westphal). 

The  exacerbations  frequently  occur  in  a,ssociation  with  distinct 
somatic  symptoms  (states  of  cerebral  excitement,  congestion  with 
sleeplessness,  salivation,  etc.),  or  with  psychic  symptoms  (dreamy  pro- 
occupation,  which  may  reach  the  degree  of  ecstasy;  stuporous  dull- 
ness; hallucinatory  confusion  with  innumerable  delusions;  maniacal 
states  of  excitement  with  impulsive  acts ;  imperative  ideas  and  ac- 
tions; verbigeration,  etc.).  In  these  states  of  predominating  activity 
of  the  unconscious  psychic  sphere  new  series  of  delusions  are  formed. 

A  point  of  great  importance  in  the  estimate  of  the  clinical  case 
and  its  course,  which  up  to  the  present  time  has  been  little  appreci- 
ated, is  the  occurrence  of  other  psychoses  in  the  course  of  paranoia. 
Eepeatedly  have  I  seen  dementia  paralytica  develop.  Alcoholic  and 
epileptic  insanity  are  not  very  infrequent,  and  also  periodic  forms  of 
mental  disturbance,  episodic  melancholia,  and  hallucinatory  insanity. 

It  is  also  worthy  of  remark  that  one  clinical  form  of  paranoia 
may  have  an  abortive  course,  in  that  another  form  takes  its  place. 


376  SPECIAL  PATHOLOGY  AND  THEllAi'Y  UF  INSANITY. 

Thus,  for  example,  original  paranoia  is  abortive,  and  late  para- 
noia occurs.  It  also  happens  sometimes  that  typic  persecutory  late 
paranoia  becomes  transformed,  under  the  influence  of  alcoholic  ex- 
cesses, to  alcoholic  paranoia;  or  that  querulous  paranoia  is  overcome 
by  a  simple  persecutory  paranoia;  or  that  simple  persecutory  para- 
noia is  replaced  by  erotic  or  religious  paranoia.  In  contrast  with 
cases  in  which  there  occurs  a  simple  transformation  of  the  delusions, 
it  is  to  be  remarked  that  the  original  form  becomes  latent,  as  if  by 
an  intermission,  and  the  new  form  seems  independent;  in  so  far  as 
it  appears  to  arise  primarily,  with  a  distinct  stage  of  incubation,  and 
develops  thus  to  the  height  of  the  disease. 

The  final  terminations  of  paranoia  are  states  of  mental  weak- 
ness, which,  however,  are  more  characterized  by  emotional  dullness 
than  by  intellectual  defects;  and  in  any  event  the  former  artistic  and 
mechanical  capabilities  of  the  patients,  as  well  as  their  power  of  judg- 
ment, are  left  unaffected.  These  persecuted  heroes,  gods,  and  kings 
of  asylmns  often  remain  to  the  very  end  of  their  lives  the  valued 
workers  of  the  institution,  which  has  become  their  second  home;  and 
this  happens  the  more  readily  because  the  delusional  ideas  gradually 
fade,  hallucinations  become  less  frequent,  and  both  lo;-e  their  influ- 
ence upon  the  emotions. 

At  any  rate,  the  nature  and  process  of  paranoia  do  not  lead  to 
dementia.  When  paranoiacs  dement  there  is  certainly  some  compli- 
cation. Dementia  is  here  the  result  and  the  expression  of  precocious 
senility,  alcoholic  excesses,  or  onanism;  or  the  termination  of  com- 
plicating psychoses. 

A  detailed  description  of  the  disease-pictures  which  paranoia 
presents  requires,  in  the  first  place,  a  division  of  the  material.  Such 
a  classification,  in  tlie  present  state  of  our  knowledge  of  the  nature  of 
these  conditions,  must  remain  purely  empiric  and  depend  upon  the 
time  of  the  occurrence,  the  peculiarities  of  etiology  and  the  course, 
and  the  symptomatic  details.  It  is  to  be  noted  that  certain  cases 
begin  in  the  period  of  childhood  (original) ;  others  occur  only  at  the 
time  of  full  mental  development  (late).  In  accordance  with  etiologic 
circumstances,  which  give  features  to  the  disease-picture  among  the 
late  forms,  we  may  distinguish  simple  paranoia,  or  typic  paranoia,  in 
contrast  with  forms  of  neurasthenic,  hysteric,  hypochondriac,  alco- 
hohc  paranoia,  etc.  In  addition,  the  typic  content  of  the  delusions 
(comp,  page  77)  is  not  without  clinical  significance  in  classification. 
It  is,  in  any  event,  not  accidental,  and  in  classification  it  must  be 
taken  in  consideration,  since  there  are  forms  of  depressive  and  ex- 
pansive delusions. 


PSYCHIC  DEGENERATIONS.  377 


I.  Original  Paranoia. 


By  the  term  "original  paranoia/"  in  contrast  with  the  following 
group  of  late  paranoia,  I  understand  cases  that  began  before — or,  at 
the  latest,  during — the  period  of  puberty. 

These  patients  are  always  profoundly  and  without  cxt-eption 
hereditarily  tainted,  and  from  their  earliest  youth  have  shown  abnor- 
mal mental  reaction;  in  whom,  according  to  Sander's  excellent  ex- 
pression, in  the  course  of  mental  development  the  disease  progresses 
as  the  healthy  mind  unfolds  in  the  normally  constituted  individual. 
This  form  is  much  more  infrequent  than  the  late  form.  In  550  cases 
of  paranoia  I  have  observed  it  16  times  (10  females,  6  males).  The 
taint  shows  itself  somatically  in  the  early  occurrence  of  genuine  con- 
stitutional neuroses  (neurasthenia,  hysteria,  hypochondria);  in  ab- 
normally early  or  perverse  manifestation  of  the  sexual  instinct,  rarely 
with  absence  of  onanism;  in  a  tendency  to  delusions  arising  out  of 
somatic  disturbances — febrile  diseases  or  exacerbations  of  the  neu- 
rosis. 

The  psychic  taint  reveals  itself  in  the  character;  in  a  relaxed, 
languishing,  sentimental  tendency,  inclining  to  hypochondria  and 
eroticism;  in  sensitiveness,  emotionality,  and  readiness  to  feel  huit 
(morally). 

The  symptoms  of  the  stage  of  incubation  may  sometimes  be 
traced  back  even  to  the  fourth  year  of  life.  Such  children  think 
that  they  are  not  treated  by  their  parents  with  the  same  love  that 
is  shown  their  brothers  and  sisters;  that  they  are  Cinderellas.  This 
feeling  of  being  neglected  is  so  painful  to  them  as  to  destroy  all 
pleasure  in  life.  They  seek  and  find  substitiites  outside  of  their 
homes.  The  atmosphere  at  home  is  not  noble  enough  for  them, 
and  they  feel  drawn  toward  higher  classes  of  society.  Actually, 
these  delicate,  pale,  dreamy,  and  sentimental  individuals,  precocious 
in  mental  and  physical  development,  find  consideration  among  kir.d 
neighbors  and  others.  Friendly  words,  harmless  flattery,  especially 
coming  from  those  of  higher  station,  make  deep  impressions.  Feel- 
ings develop  of  being  destined  for  something  higher.  In  dreams  and 
delirium  come  ideas  of  belonging  to  the  higher  class  of  society. 
These  are  carried  over  into  waking  life  and  become  the  starting- 
points  of  air-castles  and  high-flown  ambitions. 

At  this  point  of  development  primordial  delusions  of  a  distin- 
guished origin  may  occur,  but  they  usually  disappear  quickly.  The 
supposed  unkind  treatment  at  home,  the  actual  or  assumed  kindness 
of  other  people,  afford  nourishment  to  such  dreams. 


378  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  idea  of  being  tlie  child  of  other  pcopk^  hocomos  more  and 
more  powerfuL  The  patients  notice  hii'k  of  ivsembhincc  with  their 
rainily.  and  accidental  reseiuhlance  to  portraits  o!"  rciiiiiin^-  in-inecs 
or  distinguislu'd  pei'sons. 

When  such  pei'sons  are  spoken  of,  tlie  false  parents  become  pale 
and  einhai'rassed.  Concealed  in  this  tliert'  is  a  secret  which  the 
paiients  J'eel  foi'ci'd  to  explain.  ^'o\v  hysteri(\,  delirious,  e\ce[ilional 
states;  even  dreams  and  paralogie  explanation  of  events  of  waking 
life;  expressions  of  others;  adNcrtisements  in  the  newsiJajiers,  and 
passages  in  nowls,  all  become  the  keystone  of  I  he  fuliii'e  delusion. 

The  patient  sees  with  constantly  growing  cleai-ness  that  he  is 
only  an  adopted  cliild  of  the  people  that  say  they  are  his  actual 
l)a  rents. 

Respectful  salutations  on  the  part  of  others  increase.  From 
time  to  time  the  adopted  father  or  adopted  mother  let  drop  indi- 
cations of  higher  origin,  of  great  fortune^  of  the  letters-patent  of 
nobility;  but,  as  a  rule,  the  parents  are  on  their  death-bed  and  die 
at  the  moment  when  the  secret  was  to  have  been  revealed.  Gradually 
the  patient  learns  this  l)y  moans  of  illusions  and  hallucinations  of 
hearing.  Eeniinisccnces  from  dreams  and  delusions  of  corresponding 
content,  which  are  taken  for  reality  (illusions  of  memory),  are  im- 
portant aids  in  the  elaboration  of  the  romance  and  the  delusion.  The 
fancy  develops  out  of  the  dark  mysterious  future  quite  typic  romances 
of  having  been  kidnaped  in  early  youth  from  the  parental  princely 
castle  by  robbers,  gypsies,  etc.  Now  the  patient  sees  clearly  the  sig- 
nificance of  the  former  suspicious  neglect,  which,  as  a  child,  was  so 
painfully  felt  in  contrast  with  the  treatment  of  his  brothers  and 
sisters.  The  fixation  of  the  delusion  takes  place  often  with  extreme 
slowness.  Such  patients  seek  many  years  after  the  princely  famüy, 
and  belong  first  to  this  and  then  to  that  distinguished  race. 

In  females,  in  its  course,  there  is  regularly  an  erotic  element:  a 
manifestation  of  erotic  paranoia;  a  romantic  love  for  some  distin- 
guished person.  As  a  result  of  this  there  are  love-scenes,  weddings, 
and  childbirths  in  dreams  and  hallucinatory  delirium,  especially 
upon  an  hysteric  basis.  Too,  in  the  waking  state  errors  of  the  senses, 
mistaking  of  persons,  and  paralogic  significance  given  to  what  is  read 
play  an  important  role  in  this  love-romance. 

Episodically  delusions  of  persecution  are  observed,  sometimes 
entirely  primordial  creations,  but  usually  due  to  conflicts  and  ob- 
stacles which  the  paranoiac  delusion  meets  in  the  external  world. 
The  further  course,  a  formal  romance  of  persecution  and  grandeur, 
is  essentially  like  that  of  late  paranoia,  especially  in  its  hysteric  and 


rSYCiflC  DEGENERATIONS.  379 

onanistic  clinical  form.  The  inlirnnissions,  which  may  last  even 
)'ears,  are  remarkable.  Important  in  the  diagnosis  of  this  form  of 
paranoia,  aside  from  its  manner  of  origin  and  its  beginning  before 
puberty,  are  the  romantic  character  of  tlie  delusions  with  predom- 
inating ideas  of  grandeur,  and  the  typic  reciirrence  of  the  delusion  of 
coming  from  a  family  of  high  station  and  of  being  only  the  adopted 
child  of  the  parents.  Worthy  of  remark  are  the  extreme  variability 
of  the  content  of  the  delusions,  along  with  the  constant  delusional 
nucleus;  the  powerful  influence  of  constitutional  neuroses  (espe- 
cially hysteria),  with  the  great  psychic  valuation  of  the  symptoms  of 
the  neurosis;  and,  finally,  the  early  occurrence  of  confusion  (due  to 
innumerable  errors  of  the  senses,  ilhisions,  hallucinations,  etc.),  in 
which  the  patient  may  present  the  picture  of  primary  hallucinatory 
insanity. 

Case  22. — Original  paranoia. 

Victoria  K.,  aged  26,  single,  waitress,  was  admitted  to  the  psychiatric 
clinic  October  22,  1879.  Her  mother  was  psychopathic,  and  two  of  the 
mother's  brothers  Avere  insane.  The  patient  when  received  Avas  fantastically 
arrayed  with  black  and  yellow  ribbons,  pictures,  and  cheap  jewelry.  It  was 
said  that  for  a  year  she  had  acted  like  the  queen  and  empress,  occasionally 
threatening  to  imprison  and  disembowel  those  around  her.  She  entered  the 
clinic  with  high  and  condescending  mien,  where  she  expected  to  be  crowned. 
Even  as  a  little  child  she  had  never  been  liappy  in  her  parents'  house.  She 
had  always  seemed  to  be  a  stranger,  like  a  step-child.  She  had  to  endure  many 
hardships  and  much  work.  She  had  been  treated  severely  and  Avithout  love, 
ridiculed  and  persecuted.  She  had  wept  days  at  a  time  and  thought  of  her 
sad  fate.  Relatives  reported  tliat  from  her  childhood  she  had  never  been  like 
other  children — quiet,  dreamy,  easily  injured,  sensitive,  exalted,  romantic. 

The  patient  remembers  a  frightful  vision  she  had  at  the  age  of  seven.  At 
the  age  of  nine  she  developed  her  ideas  of  high  origin.  She  felt  that  she  Avas 
highly  endoAved  and  extremeb/  distinguished  as  compared  with  companions  of 
her  own  age.  Often  in  playing  the  thought  came  to  her  of  Avhether  she  Avas 
not  really  an  empress. 

In  her  tAvelfth  year,  as  a  result  of  the  imkind  treatment  of  her  parents, 
she  noticed  that  there  must  be  some  secret  in  her  future.  She  felt  that  her 
brothers  and  sisters  euA'ied  her.  The  conduct  of  people  seemed  more  and  more 
strange  to  her.  By  her  parents  and  some  other  persons  of  her  acquaintance 
she  was  repulsed;  but  others  Avere  friendly  and  even  respectful.  One  day  her 
teacher  said  to  her,  "Victoria,  you  are  a  relatiA'e  of  the  Queen  of  England  (by 
name)."  This  made  a  profound  impression  upon  her.  Later  she  often  heard 
called  after  her:  "Victoria  of  England,  thou  beautiful  bride."  Occasionally 
she  also  heard  insulting  Avords. 

She  began  noAv  to  think  and  occupy  herself  Avith  all  kinds  of  romantic 
ideas. 

At  the  age  of  fifteen  the  menses  occurred  Avith  chlorotic  and  nerA'Ous 
symptoms.  At  the  age  of  sixteen  she  had  a  "blood  disease"  (morbus  macu- 
losus?).     At  that  time  she  felt  that  her  blood  Avas  becoming  blue,  and  ex- 


380  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

plained  thus  the  blue  spots  on  her  skin.  Now  she  noticed  that  the  people  met 
her  as  if  she  "were  a  queen.  Occasionally  she  saw  a  picture  of  the  Queen  of 
England,  and  remarked  the  resemblance,  so  that  she  thought  she  must  be  a 
daughter  of  this  queen.  The  people  often  called  her  ''Victoria  of  Schwaben- 
land." As  a  result  of  tlie  conversation  of  her  relatives,  as  well  as  irom  slight 
indications' of  the  pastor  on  the  occasion  of  a  procession,  she  tliought  that  she 
was  tlie  daught-ei'  of  the  Queen  of  England  and  that  she  had  been  taken  from 
her  mother  to  her  adopted  parents  when  she  was  three  months  old.  These 
perverted  ideas,  arising  from  t)ccasional  conversation,  slie  could  not  get  out  of 
her  head,  and  she  found  in  them  indications  of  her  future,  and  elaborated  them 
further  in  her  dreams. 

At  the  age  of  21  she  had  a  love-afTair  with  a  tea-cher.  After  intercourse 
with  him  she  had  a  divine  dream  in  which  she  saw  herself  the  mother  of  Clu-ist. 
Even  at  that  time,  in  1S74,  she  often  liad  the  thought  that  her  lov^er  was  the 
crown  prince.  This  supposition  became  certainty  when  one  day  the  teacher 
put  a  ring  on  her  finger  and  then  looked  at  her  and  at  the  picture  of  their 
majesties  which  was  hanging  in  the  room.  At  that  moment  she  discovered  his 
lesemblance  to  the  emperor.  Tlie  people  also  let  her  see  that  they  thought 
she  was  the  bride  of  the  crown  prince,  and  that  they  knew  that  she  was  a 
princess  of  England. 

After  1876  the  disease  made  rapid  progress,  in  that  the  impressions  from 
the  outer  world  became  more  and  more  erroneous,  and  the  patient  developed 
into  a  romantic,  fantastic  personality,  and  began  to  act  in  accordance  with  her 
delusions. 

Single  words  caught  in  conversation,  notices  in  the  papers,  things  read 
on  pieces  of  paper,  dreams,  etc.,  became  the  foundation-stones  of  her  delusional 
creations.  Accidental  passages  in  novels,  which  she  cited  even  after  years,  as 
"Thou,  queen  of  all  queens,  thou  art  like  a  picture  of  the  Virgin,  thou  beauti- 
ful Angela,"  etc.,  she  referred  to  her  princely  origin.  A  novel  in  the  paper 
called  Heimgarten  made  an  especially  profound  impression  on  her.  She  read 
in  it  her  entire  life-liistory.  The  part  "The  Past"  was  dark  and  sad.  When 
she  wished  to  read  the  part  "The  Future,"  the  pages  of  which  were  folded,  the 
book  disappeared  by  chance.  Tlius  her  future  remained  unrevealed.  She 
noticed  this  much  in  her  reading — that  she  was  already  a  queen  and  that  she 
would  become  an  empress. 

On  the  occasion  of  a  dream  in  1877  it  became  clear  to  her  that  she  was 
no  "Katzian."  She  saw  her  adopted  father  in  prison  upon  a  pallet,  and  on  tlie 
right  of  him  a  dog,  the  symbol  of  truth ;  at  the  left  a  cat,  that  of  deception, — 
Katzian, — and  thus  she  wa.s  the  false  Katzian.  ^\'lle^  she  went  to  church  on 
(Christmas,  1878,  and  remarked  the  son  of  the  house,  Joseph,  the  thought  came 
to  her  that  she  might  be  the  Virgin  Mary;  and  later  when  she  went  into  llie 
cellar,  and.  thinking  of  her  lover,  looked  at  a  light,  she  thought  that  it  was 
tlie  fire  of  love.  "When  she  afterward  went  to  bed  she  experienced  heavenly 
happiness.  Her  mouth  wa-s  full  of  sweetness  and  her  hands  were  like  sweet- 
smelling  flowers.     In  ten  minutes  all  was  over. 

Soon  after  her  admission  to  the  asylum,  the  patient  became  the  Empress 
Concordia,  which  name  she  had  learned  in  Schiller's  "Glocke."  The  articles 
with  which  she  ornaments  herself  are  explained  in  the  most  perverted  way. 
A  red  band  around  her  throat  signifies  love;  a  white,  innocence;  a  yellow  and 
black,  her  imperial  origin.     The  picture  of  a  child  in  a  copper  frame  with  a 


PSYCHIC  DEGENERATIONS.  381 

crown-like  oniamont  signiMos  pa.illy  tlic  divine  eliild  and  pnrlly  ilie  impfiiai 
crown.  "The  ci'own  should  be  a  ball  and  a  cross.  The  ball  signifies  that  I 
I)ossess  lands;  the  cross,  that  I  have  been  forced  to  boar  much  torment  and 
sntl'ering  in   life." 

The  delusions  are  soon  projected  into  her  new  smroundings.  Tiic  rhicf 
attendant  is  the  Queen  of  England;  the  professor,  the  emperor;  one  of  the 
physicians,  tlie  crown  prince.  The  chief  attendant  had  taken  her  position  out 
of  pure  maternal  love.  Another  attendant  becomes  lier  former  lover.  Tlje 
other  patients  are  princes  in  disguise  who  struggle  to  obtain  her  hand.  The 
patient  demands  that  here  finally  an  end  be  made  to  this  scandal  by  giving 
consent  in  order  that  it  might  be  known  who  was  husband  and  wife.  She 
thought  that  it  must  be  terribly  distressing  to  the  men  -to  be  always  going 
about  in  women's  clothes.  All  day  long  the  patient  is  bedecked,  awaiting  her 
final  coronation.  Many  imperial  messengers  come  to  her.  She  is  very 
gracious,  condescending,  also  often  erotic,  irritated,  and  excited,  because  she 
is  always  seeking  after  her  high  family,  and  cannot  understand  whether  she 
belongs  to  the  English  or  Austrian  royal  house.  She  asks  for  the  journal 
called  Heimgarten,  that  she  may  read  her  entire  future  in  it;  uncertainty 
is  frightful. 

She  cannot  understand  the  news  that  the  crown  prince  is  to  marry  a 
Belgian  princess.  Everything  is  understood  in  a  crazy  way.  The  princess  comes 
to  Salzburg  (=  salt — i.e.,  bitter;  burg — i.e.,  asylum — bitter  sojourn) ;  then  to 
Schonbrunn  (=  branch  of  the  asylum  before  which  there  is  a  beautiful 
spring) ;  the  engagement  ceremony  takes  place  in  the  Church  of  the  Augus- 
tines (=n  the  chapel  which  is  near  the  institution,  and  which  the  patient 
entered  for  the  last  time  in  August). 

The  patient  is  tall,  stately,  without  anatomic  signs  of  degeneration,  and 
with  neuropathic  eyes  and  lang\iid  expression.  Menses  profuse,  dysmenor- 
rhea, uterus  virginal  and  decidedly  anteverted.  The  whole  impression  made 
by  the  patient  is  that  of  exquisite  paranoia.  In  the  course  of  the  last  two 
years  the  delusions  have  undergone  no  further  elaboration.  They  are  less 
frequent  and  expressed  with  less  emotional  accompaniment. 

II.  Late  (Acquired)  Paeaxoia. 

The  outbreak  of  this  form  of  paranoia  always  takes  place  after 
the  period  of  puberty,  not  infrequently  first  in  the  fifth  decennium, 
and  in  females  especially  in  connection  with  the  changes  of  the 
climacteric.  But  in  any  other  earlier  period  of  life  the  outbreak  may 
come,  and  it  is  distinctive  of  the  severity  of  the  taint  to  note  how  in- 
significant the  exciting  causes  may  be.  The  nucleus  of  the  delusions 
of  these  patients  lies  in  ideas  of  persecution  and  grandeur. 

.  In  many  cases  the  disease-picture  is  made  up  exclusively,  or  al- 
most exclusively,  of  one  or  the  other  form  of  these  primordial  delu- 
sions. More  frequently,  however,  it  happens  that,  seemingly  in 
accordance  with  a  law,  one  form  of  delusion  develops  out  of  tbe 
other,  overcoming  that  which  first  appeared;  and  under  such  circum- 
stances the  persecutory  ideas  are  always  those  that  first  manifest 


382  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

themselves.  In  this  case  the  disease-picture  is  made  up  of  ideas 
of  ])erseeutory  eoiitent  (perseeiitoiT  insanity),  yet  episodically  mani- 
festations of  conipliuientary,  but  abortive,  ideas  of  grandeur  are  not 
excluded. 

Tavo  forms  may  be  (.liU'erentiated  : — 

(A)  Forms  with  i)riniary  and  predominating  tlclu.-ioiis  of  injury 
to  the  jjersonality  (persecutory  insanity):    pcrsecutorij  paranoia. 

(B)  Cases  presenting  primary  and  i)redominating  delusions  of 
benetlt  to  the  interests  of  the  personality  (delusions  of  grandeur): 
expansive  paranoia.  > 

(A)  Pj:ksi:('(  TORY  Pauaxoia. 

This  is  the  most  frequent  form.  i\.s  empiiically  distinct  clinical 
pictures  there  are  the  following: — 

1.  The  Tj/pic  Form  of  Acquired  Paranoia. 

The  subjects  of  this  malady  are,  for  the  most  part,  from  child- 
hood on,  peculiar,  quiet,  retiring,  uncommunicative,  easily  injured, 
irritable,  suspicious,  and  not  infrequently  inclined  to  hypochondria. 
The  disease-picture  begins  with  delusions  of  persecution. 

The  nucleus  of  the  delusions  of  this  great  and  practically  im- 
portant group  of  patients  lies  in  the  delusion  of  injury  to  the  health, 
life,  honor,  or  fortune  of  the  individual  by  enemies.  The  stage  of 
incubation  is  usually  long,  and,  for  the  most  part,  escapes  observation. 

Where  this  period  is  observed,  on  the  somatic  side  there  are  the 
clinical  symptoms  of  exciting  causes  (gastric  catarrh,  uterine  disease, 
climacteric,  neurasthenia  due  to  onanistic  excesses),  or  symptoms  of 
an  hypochondriac  or  hysteric  neurosis,  usually  of  a  constitutional  na- 
ture. On  the  psychic  side  there  is  elaboration  of  the  fancies  above 
referred  to,  which  may  become  illusions.  The  persons  about  the 
patient  seem  strange  and  even  suspicious.  The  external  world  seems 
in  general  to  be  changed,  especially  in  reference  to  the  personality 
of  the  patient.  It  seems  to  him  as  if  the  world  did  not  wish  him 
well;  that  there  was  something  against  him  in  the  air.  He  feels 
himself  the  object  of  annoying  attention,  and  becomes  himself  at- 
tentive (delusion  of  suspicious  attention).  He  assumes  that  in  his 
neglect  of  dress  and  in  his  secret  vices,  which  his  face  reveals  to 
others;  and  in  former  faults  and  crimes  which  have  presumably  be- 
come known,  lie  the  cause  of  the  change  in  those  about  him.  Acci- 
dental, hannless  remarks  by  others;  frequently  meeting  the  same 
person ;  accidental  departure  of  those  that  were  present  when  he  enters 
a  room;  the  passers-by  that  avoid  him  or  stop;   clearing  the  throat 


PSYCHIC  DEGENERATIONS.  383 

or  coughing, — strengthen  his  suspicion.  Now  and  then  he  recognizes 
that  he  deceives  himself,  bnt  owing  to  his  originally  illogic-al  niind  and 
his  mental  uncertainty  and  indecision,  new  reasons  for  suspicion  in- 
crease. The  preacher  refers  to  him  in  his  sermon.  In  the  news- 
papers and  advertisements  on,  the  walls  he  discovers  references  to 
misdeeds,  crimes,  intimate  relations,  etc.  Public  opinion  blames  him. 
He  is  taken  for  a  fool,  a  1);ul  fellow,  an  imbecile.  People  point  him 
out,  ridicule  him,  insult  lüni,  look  at  him  askance.  In  the  harmless 
conversation  of  others  he  takes  up  words  and  brings  them  into  rela- 
tion with  himself,  and  later  he  hears,  under  similar  circumstances, 
shameful  remarks.  The  street  boys  whistle  street  tunes  which  refer 
to  him;  and,  in  fact,  the  want  of  critical  power  may  be  so  intensified 
that  the  patient  hears  shameful  things  in  the  twittering  of  the 
birds.  An  effort  is  made  to  injure  him  in  the  eyes  of  those  above 
him,  and  compromising  papers  and  objects  are  sought  in  his  effects, 
in  order  to  blacken  his  character,  to  make  him  the  scapegoat  of 
others,  etc. 

The  patient  is  made  anxious  by  these  suspicious  ideas,  and  he 
becomes  more  shy,  retiring,  and  irritable  than  before.  He  retreats 
more  and  more  from  society,  brooding  and  thinking  over  the  dark 
ideas  of  hostility  and  repression.  Occasionally  he  also  reproaches 
people  with  their  hostile  conduct. 

The  transition  to  the  height  of  the  disease  may  be  sudden,  with 
a  violent  attack  of  apprehension  which  calls  up  into  consciousness 
a  host  of  long-prepared  hallucinations  and  delusions.  More  fre- 
quently, however,  it  is  gradual,  with  the  imaginary  ideas  taking  on 
more  and  more  the  character  of  illusions,  the  reasons  for  suspicion 
becoming  more  frequent,  until  finally  an  accidental  event  changes 
the  previous  latent  delusion  to  certainty,  and  hallucinations  occur. 
Some  slight  disturbance  of  physical  health— a  febrile  disease,  a 
gastric  catarrh,  an  intensification  of  uterine  or  climacteric  troubles, 
increased  onanistic  excesses,  a  few  sleepless  nights — frequently  is 
sufficient  to  bring  about  the  development  of  the  disease  to  its  acme. 
The  patient  suddenly  reaches  the  frightful  certainty  that  he  is 
poisoned.  He  hears  voices  that  threaten  his  life.  The  delusion  has 
an  overpowering  effect.  The  patient  now  has  the  terrible  certainty 
of  what  he  had  suspected.  With  surprising  rapidity  the  delusions 
become  systematized,  in  which  process  hallucinations  of  hearing  play 
their  part.  In  accordance  with  political  ideas  or  social  position,  the 
patient  is  the  victim  of  a  band  of  Jesuits,  Free  Masons,  Socialists, 
Spiritualists,  or  the  like;  or  he  is  persecuted  by  the  secret  police, 
neighbors,  or  this  or  that  coiupauion,  associate,  etc.    He  is  terribly 


384  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANTIY. 

frightened  and  robbed  of  reason.  The  delusions  of  persecution  are 
rapidly  generalized;  imaginary  ideas,  illusions,  hallucinations,  and 
delusional  ideas  pervert  external  events. 

Here,  under  such  circumstances,  errors  of  the  senses  ail'ord  the 
greatest  aid.  It  is  only  rarely  that  they  are  wanting  or  limited  to  the 
form  of  illusions.  Voices  play  the  most  important  part.  They  seem 
to  come  from  near  or  far;  and  Avhen  the  disease  is  well  along  also 
even  from  parts  of  the  body.  Later,  conscious  thoughts  are  changed 
into  hallucinations  (the  enemies  guess  the  patient's  thoughts,  spy  on 
them,  etc.).  The  patients  differentiate  the  various  voices  and  give 
them  particular  significance.^  The  voices,  as  articulate  reactive 
events  in  the  unconscious  sphere,  reveal  the  secret  plans  of  the  perse- 
cutors and  tell  their  names;  often  quite  senseless  connections  of 
sounds  enable  the  names  to  be  discovered. 

Of  next  importance  are  the  errors  of  general  sensibility  and 
cutaneous  sensibility.  All  possible  physiologic  and  pathologic  sensa- 
tions are  interpreted  in  the  sense  of  persecution.  There  are  insects 
and  snakes  on  the  skin  and  animals  in  the  stomach.  The  persecutors 
destroy  health  ■with  poisonous  odors,  powders,  and  secret  niacliines. 
They  steal  organs,  and  commit  sexual  vices,  coitus,  etc.  Less  fre- 
quently gustatory  and  auditory  errors  occur.  Without  exception  they 
are  of  hostile  and  unpleasant  content.  Food  tastes  of  arsenic,  chloro- 
form, feces,  etc.;  drink,  like  urine.  Everything  smells  of  decay  and 
burned  feathers.  These  simultaneous  sensations  strengthen  the  pa- 
tient in  the  conviction  that  an  attempt  to  destroy  his  health  and  life 
is  being  made. 

Hallucinations  of  sight  are  the  least  frequent.  They  occur  but 
episodically,  may  be  of  quite  indifferent  content,  and  are  not  assim- 
ilated by  the  delusion.  Only  in  very  rare  cases  is  there  a  shadow-like 
perception  of  the  persecutor. 

As  a  reaction  to  the  abnormal  hostile  events  taking  place  in  con- 
sciousness, the  patients  develop  emotional  states.  These  may  be  very 
lively;  but,  aside  from  occasional  attacks  of  apprehension  as  spon- 
taneous manifestations,  these  are  secondary  and  natural,  and,  as  it 
were,  the  physiologic  reaction  to  the  primary  change  of  the  ego  and 
its  relation  to  the  outer  world  brought  about  by  the  delusional  ideas. 


^  One  of  my  patients  differentiates  talk  by  telegraph:  i.e.,  voices  that 
come  from  a  distance  not  clear  and  indistinctly  heard,  and  "Ausstaffiren " : 
i.e.,  guessing  of  thought.  Whatever  she  thinks,  those  around  her  know  imme- 
diately. Her  son,  whom  she  bears  now  four  years,  speaks  to  her  in  telegrapMc 
speecb. 


PSYCHIC  DEGENERATIONS.  385 

In  this  primary  non-affective  manner  of  origin  of  the  ideas  of 
the  paranoiac,  devoid  of  relation  to  intensified  or  diminished  feeling 
of  self,  lies  a  decisive  point  of  differentiation  of  this  disease  from 
melancholia  or  mania  with  delusions  (the  delusional  insanity  of  some 
authors). 

In  these  diseases  the  content  of  the  delusions  may  be  the  same, 
but  they  have  an  entirely  different  motive.  The  paranoiac  does  not 
know  how  it  happens  that  he  is  persecuted.  He  has  not  deserved  it. 
Only  gradually  and  in  a  logical  way  does  he  arrive  at  the  conclusion, 
that  he  is  the  victim  of  a  conspiracy  or  the  like.  The  melancholic 
knows  only  too  well  why  he  is  persecuted  and  is  approaching  a  shame- 
ful death.  He  has  deserved  death,  for  he  is  a  wicked  fellow.  His 
delusions  are  the  secondary  product  of  affective  conditions.  They 
move  about  a  diminished  feeling  of  self,  and  therein  have  their  root 
(micromania,  delusions  of  sin). 

With  great  justice  Schule  says  that  the  developed  delusion  in 
the  paranoiac  has  a  relieving  influence,  whereas  the  delusion  created 
in  the  explanatory  efforts  of  the  melancholic  has  a  depressing  effect. 

Too,  the  acts  of  a  person  suffering  with  delusions  of  persecution 
are  essentially  only  the  logical  and  natural  reaction  of  a  consciousness 
which  presumes  its  existence  to  be  threatened. 

With  reference  to  the  conduct  of  the  patients  in  relation  to  their  delu- 
sions, two  stages — one  of  passivity  and  the  other  of  activity — are  to  be 
differentiated.  At  first  the  patients  are  passive  and  on  the  defensive  toward 
the  delusionally  conceived  external  world.  They  avoid  it,  close  the  windows 
and  doors,  stop  up  the  keyholes,  and  change  their  dwelling  frequently.  They 
cook  their  own  food  or  live  only  on  raw  eggs,  etc.,  treat  themselves  with  anti- 
dotes, flee  to  foreign  lands,  or  take  other  names  in  order  to  save  themselves 
from  their  persecutors. 

Then  the  condition  grows  more  and  more  painful,  becomes  unbearable. 
They  change  from  their  passive  state ;  but  before  they  become  dangerous  they 
usually  give  premonitory  signals  of,  the  approaching  storm,  which,  however, 
only  too  frequently  remain  unnoticed. 

They  threaten  their  supposed  persecutors,  apply  to  the  courts  for  protec- 
tion, until,  sadly  convinced  that  their  efforts  are  vain,  they  are  forced  to  help 
themselves,  and  find  themselves  in  a  position  where  they  are  driven  to  defend 
themselves.     At  this  stage  the  patient  is  extremely  dangerous. 

Hallucinations,  emotional  illusions,  or  a  supposed  suspicious  look,  a 
whisper,  a  suspicious  gesture,  indicate  a  threatening  danger  and  lead  to  mur- 
derous acts,  which  have  all  the  features  of  a  supposed  justifiable  act  of  self- 
defense. 

Patients  of  this  group  never  commit  secret  murders;  rather,  they  sacri- 
fice their  victim  in  broad  daylight  and  before  witnesses.  They  do  not  conceal 
their  motive,  and  take  delight  in  the  success  of  their  deed.  Sometimes  it  hap- 
pens that  they  attack  some  quiet,  indifferent  person,  commit  almost  any  crim- 


386  SPECIAL  TATHOLOGY  AXD  THERArY  OF  INSANITY. 

inal  act,  in  order  to  be  brouglit  before  the  court,  which  shamefully  persecutes 
them  and  fails  to  ans^Yer  their  appeals.  Sometimes  thej'  commit  suicide  in 
order  to  end  their  unbeiuable  persecution. 

The  patient  passes  on  directly  into  a  state  of  terminal  mental 
weakness;  or  tranftfurnialion  of  the  delusions  takes  place.  The  pa- 
tients, persecuted  and  repressed  up  to  this  period,  become  princes, 
emperors,  prophets,  God,  messiahs,  rulers  of  the  world,  queens  of 
heaven.  This  interesting  transformation  of  tlie  jjcrsonalit)^  occurs 
in  at  least  one-third  of  the  cases,  and,  as  far  as  my  observation  goes, 
exclusively  in  lliose  of  an  hereditai'y  nature. 

The  regularity  of  tliis  process  is  imequivocal;  its  cause,  however,  is  not 
immediately  apparent. 

Only  in  a  certain  number  of  cases  can  it  be  proved  that  this  con^pensatory 
delusion  of  grandeiir  arises  in  a  conscious  psychologic  way,  in  that  the  un- 
fortunate patient  seeks  comfort  in  religion  or  air-castles.  It  must  also  be 
acknowledged  that  a  patient  who  looks  upon  himself  as  the  object  of  general 
attention  easily  develops  the  thought  that  there  is  in  him  some  particular 
quality,  and  therefore  there  is  in  the  delusional  idea  of  being  observed  a  psy- 
chologic element  which  may  give  rise  to  the  future  delusion  of  grandeur.  But 
these  psychologic  cxi)lanations  are  not  fully  satisfactory. 

Tlicre  is  much  which  goes  to  show  that  the  transformation  is  not  devoid 
of  an  organic  foundation;  that  it  arises  out  of  the  nervous  mechanism,  and 
takes  place  essentially  imconsciously  and  intuitiveh\ 

The  transformation  may  take  place  suddenly — under  such  circumstances 
not  infrequently  there  are  changes  of  sensation  as  a  basis  (feeling  of  magnetic 
currents,  changed  molecular  conditions  in  the  central  organ?);  or  it  arises 
out  of  conscious  states  in  which  the  patient  seems  to  die  and  suddenly  to 
awake  to  a  new  and  transformed  life.  In  other  cases  the  transformation 
takes  place  in  a  stuporous  or  ecstatic  state,  a  state  of  somnolence,  or  in  a 
state  of  hysteric  delirium.  More  frequently  the  transformation  is  accom- 
plished slowly  through  a  period  of  incubation,  like  the  period  which  precedes 
the  development  of  the  delusion  of  persecution. 

The  patient  notices  that  people  look  at  him  with  attention;  a  person  of 
high  station  stops  his  carriage  before  him  in  the  street;  in  the  newspapers 
there  are  indications  of  a  higher  origin.  Passers-by  and  people  at  home  meet 
him  with  respect.  He  hears  others  talking  about  him,  calling  him  a  knight, 
saying  that  a  gi-eat  fortune  awaits  him. 

Unconscious  mental  activity  further  elaborates  the  idea.  In  dream- 
pictures  the  delusion  makes  itself  felt  at  first.  There  the  patient  is  shown 
letters-patent  of  nobility,  and  reminiscences  out  of  episodic  delusions  and 
fancies  become  elaborated. 

finally  the  delusion  enters  consciousness  as  an  actual  fact,  directly  or 
as  a  result  of  hallucinations,  showing  him  to  be  the  descendant  of  a  reigning 
prince  or  the  child  of  God. 

Logical  association  with  the  previous  delusions  of  persecution  is 
found.  Now  the  patient  knows  why  his  enemies  were  interested  in 
trying  to  destroy  him  as  a  pretender,  for  he  regards  all  the  previous 


PSYCHIC  DEGENERATIONS.  387 

pcrsccuLion  as  a  stage  oi'  ])i'c])ai'aiioii  and  trial  necessary  jn  one  wlio 
was  to  become  the  nietisiali.  Jn  tlio  dominating  delusions  of  grandeur 
there  are  afterward  also  episodic  delusions  of  persecution.  Botli 
series  of  jorimordial  delusions  disappear  and  recur  one  after  another, 
and  at  times  quite  disappear.  Finally  under  such  circumstances  there 
is  a  terminal  state  of  mental  Aveakness. 

On  the  diagnostic  side,  in  contrast  with  the  secondary  delusional 
state  arising  out  of  mania,  there  are,  in  paranoia,  the  striking  mixture 
of  delusions  of  grandeur  and  persecution,  the  retention  of  intelli- 
gence, the  stability  of  the  condition,  and  the  romantic  content  of  the 
delusional  ideas. 

In  contrast  with  other  forms  of  grand  delusions,  as  they  occur, 
for  example,  and  of  no  less  extravagance,  in  paretic  dementia,  here 
the  fixed  and  systematic  character  of  the  delusional  ideas  is  to  be 
emphasized. 

The  treatment  of  this  form  of  paranoia  is  symptomatic  and  not 
wholly  without  resiüt.  In  case  of  conditions  of  sexual  irritation  and 
paralogic  hallucinatory  and  delirious  manifestations  based  on  these, 
the  bromides  in  large  doses  are  useful. 

Amelioration  is  obtained  by  the  subcutaneous  use  of  moi'phine, 
which  lessens  the  paralgic  sensations  and  the  consequent  delusional 
ideas:  and  it  is  also  applicable  in  that  form  of  paranoia,  so  frequent 
in  the  climacteric,  which  manifests  itself  especially  in  hallucinations. 

In  the  later  stages  of  the  malady  the  hospital  for  the  insane, 
with  its  means  of  mental  treatment  and  distraction  of  work,  is  very 
important  to  keep  the  patient  from  giving  up  to  his  dreams;  and  at 
the  same  time  it  affords  him  an  asylum,  in  removing  him  from  the 
ridicule  of  others,  and  thus  often  still  valuable  mental  capabilities 
may  be  usefully  employed. 

Case  23. — Typic  form  of  acquired  paranoia.  Outbreak  during 
the  climacteric. 

Anna  S.,  aged  47,  single,  was  admitted  April  23,  1SS2.  Her  father  was  a 
drinker.  Several  children  of  the  family  died  of  convulsions.  The  whole  fam- 
ily was  said  to  be  inclined  to  hypochondria,  to  be  exalted  and  irritable. 

The  patient  was  delicate  as  a  child,  well  endoAved  mentally,  and  always 
emotional,  apprehensive,  inclined  to  be  alone,  and  suspicious.  At  10  years  of 
age,  severe  disease,  with  cerebral  symptoms.  At  15,  menses,  with  severe  dis- 
turbances. Thereafter  the  menses  were  always  accompanied  with  pain  in  the 
abdomen  and  back,  and  headache. 

Since  her  foiu-teenth  year  the  patient  had  been  forced  to  depend  upon 
herself  and  sacrifice  herself  for  her  Brothers  and  sisters ;  for  lier  mother  died 
early.  The  patient  is  said  to  have  been  well  until  1876,  and  to  have  gained  her 
liveliliood  in  large  part  until  that  time.     In  1876  the  climacteric  began  (irregu- 


388  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

hir,  profuse  menses,  unilateral  headache,  congestions,  feelings  of  beat  in  the 
head,  roaring  in  the  ears,  feelings  of  anxiety,  rising  in  the  chest,  general 
fatigue).  At  that  lime  she  ac-eepted  a  position  as  a  nurse  for  an  invalid  wiio 
soon  died.  The  death  of  this  lady  impressed  her  very  much.  The  invalid  had 
promised  to  the  patient  that  if  she  -would  stay  with  her  she  would  leave  her 
her  fortune.  The  patient  inimediatelj'  noticed  that  Mrs.  E.  and  herself  were 
surrounded  by  enemies.  The  people  in  tiie  house  were  so  peculiar,  unfriendly, 
and  a  priest  tried  to  come  into  direct  relation  with  the  invalid.  The  cook  and 
a  laborer  in  the  house  helped  him  in  this.  The  cook  wished  to  have  everything 
for  herself.  Jellies  sent  from  the  dealer  arrived  opened  and  presumably  had 
been  poisoned.  The  taste  of  the  beer  and  wine  was  bad,  and  the  patient  felt 
that  she  was  made  sick  by  them.  When  Mrs.  E.,  in  eJirouis,  sent  for  the 
physician,  the  priest  arrived  with  an  accomplice  and  forced  her  to  give  every- 
tliing  to  the  church.  The  patient  arrived  suddenly  and  surprised  this  pleasant 
company. 

After  having  made  her  will,  Mrs.  E.  died  suddenly — apparentlj'  an  un- 
natural, frightful  death.  The  patient  thought  that  she  got  her  share  of  the 
poison  in  beer.  At  any  rate,  she  was  quite  miserable  and  half-paralyzed  in  her 
left  leg.  She  returned,  sick  and  excited,  to  her  sister.  In  this  condition  she 
quarreled  with  her  sister  and  expressed  the  suspicion  that  the  latter  was  also 
in  league  with  her  enemies;  and  she  sought  a  place  in  a  foreign  land  as  a 
nurse.  The  menses  did  not  return.  Up  to  1878  she  suffered  with  unilateral 
lieadache,  congestion?^,  burning  in  the  head,  feelings  of  heat,  tension  in  the 
body,  palpitation  of  the  heart,  pain  in  the  back,  suffocating  odors,  but  never- 
theless she  did  not  notice  any  more  persecution,  without,  however,  correcting 
her  delusion. 

Again  in  1879  she  felt  ill  (alternating  feelings  of  heat  and  cold;  feelings 
of  having  the  head  and  body  SAVollen).  Again  she  became  anxious  and  sus- 
picious. At  night  she  heard  taps  on  her  Avindow;  she  saw  a  man  in  the  bushes 
without  a  hat,  and  was  violently  frightened.  She  became  conscious  of  in- 
visible enemies  and  an  accomplice  in  the  crime  practiced  on  Mrs.  E.  by  the 
priest,  who  was  a  Jesuit,  and  she  was  persecuted  by  the  whole  order  of 
Jesuits.  Her  sister  invited  her  to  P.,  and  she  accepted  this  invitation  on 
November  13,  1881. 

When  she  arrived,  her  brother-in-law  grew  pale.  The  invitation  was 
only  a  trap  to  attract  her  and  to  get  rid  of  her  afterward.  Her  brother-in-law 
becomes  an  accomplice  of  the  Jesuits.  Her  sister  and  her  children  accidentally 
fall  sick.  She  remarks  that  an  effort  is  being  made  to  get  rid  of  them,  as  in 
the  case  of  Mrs.  E.  The  child  smells  of  phosphorus.  Her  sister's  breath  is 
pestilential.  The  water-closet  stinks  horribly  and  is  poisoned.  Suffocating 
atmosphere  fills  the  whole  house.  In  her  room  there  is  a  suspicious  back  door. 
At  night  dark  forms  pass  by  her  window,  come  unseen  through  the  closed  door, 
and  prepare  instruments  of  torture.  Dogs  howl  all  night.  The  patient  sleeps 
no  more  because  of  fear.  March  20th  she  ran  away  to  Gratz  to  the  house  of 
a  relative.  On  the  way  the  train  whistles  peculiarly.  Opposite  her  in  the 
compartment  there  was  a  man  with  fearful  eyes  Avho  looked  at  her  constantly 
• — apparently  a  Jesuit.  He  spoke  to  the  conductor,  and  thereafter  the  train 
went  very  slowly.     Her  head  swam  with  fear. 

When  she  arrived  in  Gratz,  weeping  she  begged  her  relatives  for  protec- 
tion for  herself  and  her  sister.     She  was  brought  back  to  P.,  and  grew  quieter. 


PSYCHIC  DEGENERATIONS.  389 

In  P.  she  had  new  suspicious  experiences.  She  found  an  umbrella  handle 
which  was  a  hand  holding  a  black  ball.  It  had  been  lost  by  the  Jesuit — the 
ball  was  a  poisonous  pill  with  which  he  wished  to  poison  her.  At  night  he 
moved  aroimd  slyly  seeking  to  get  her  in  his  power.  In  frightful  fear  she  ran 
away  again  to  Gratz  March  22d.  In  the  compartment  again  the  Jesuit  sat  up 
before  her,  looking  at  her  continually,  holding  a  satchel  in  his  hand,  wliich 
was  full  of  instruments  of  torture.  At  Gratz  he  got  out  at  the  cloister  of  the 
Brothers  of  Charity.  Evidently  he  had  designs  against  the  prior  of  the  con- 
vent;   and  the  sisters,  too,  must  await  this  slow  and  horrible  death. 

Patient  goes  willingly  to  the  hospital,  for  here  she  feels  herself  to  be  in 
security. 

She  is  of  middle  size,  without  signs  of  degeneration,  anemic,  and  witliout 
disease  of  the  vegetative  organs.  Examination  of  the  uterus  gives  a  negative 
result.  The  patient  complains  of  vag-ue  pains,  feelings  of  paralysis,  of  being 
swollen,  headache,  withoiit  objective  symptoms.  On  the  next  day  she  noticed 
also  in  the  hospital  many  suspicious  things,  became  anxious  and  very  sus- 
picious. She  thought  that  the  Jesuits  were  hanging  about  the  door,  that 
the  attendants  were  already  won  over  by  them,  and  feared  traps  at  night. 

Because  of  occasional  disturbances  of  digestion,  she  notices  that  she  is 
poisoned  with  arsenic  and  lead.  After  having  eaten  vegetables  she  felt  numb- 
ness and  trembling  in  her  whole  body.  Her  paralgic  sensations  are  inter- 
preted, in  the  sense  of  persecution,  as  being  due  to  poison  given  by  the  Jesuits. 
They  were  opposed  to  the  Imperial  House,  and  had  already  killed  the  Emperor 
Joseph.  Also  unpleasant  odors  which  she  experienced  occasionally  were  inter- 
preted in  relation  to  persecution.  The  most  harmless  occurrences,  even  the 
calling  of  the  cuckoo  and  the  croaking  of  the  frogs  in  the  park  near  by,  had 
relation  to  her.  Dr.  L.  showed  her  the  muzzle  of  his  dog.  This  meant  that 
she  must  not  speak  any  more  or  her  mouth  would  be  stopped.  A  fellow- 
patient  beckons  to  her  husband  with  her  umbrella  and  handkerchief.  She  is 
making  signs  to  the  Jesuit.  This  lady  asked  once  about  the  patient's  home — • 
she  wished  apparently  to  get  information  about  the  patient  and  give  it  to  the 
Jesuits.  When  an  attendant  once  scratched  on  the  wall  she  thought  that  it 
meant  that  the  grating  should  be  unlocked  in  order  to  facilitate  the  entrance 
of  the  Jesuits.  Accidental  visitors  in  the  ward  she  took  to  be  sworn  friends 
of  the  Jesuits  and  of  her  brother-in-law,  for  one  of  the  visitors  had  a  cane  like 
that  of  her  brother-in-law,  and  he  held  it  back  of  him  that  she  might  not  rec- 
ognize it.  In  everything  she  is  reminded  and  must  recognize  that  the  power  of 
her  enemies  reaches  to  this  j)lace.  Her  letters  have  been  seized  by  the  Post  in 
Vienna.  They  are  given  to  a  censor  and  then  communicated,  so  that  everybody 
knows  her  secrets. 

At  night  stones  are  thrown  against  the  window.  She  hears  whispers 
and  suspicious  noises.  The  existence  of  hallucinations  of  hearing  cannot  abso- 
lutely be  determined,  but  there  are  hallucinations  of  smell  and  illusions  of 
hearing  and  sight.  The  delirium  is,  in  large  part,  primordial,  and  has  arisen  in 
false  judgments  and  the  imaginary  elaboration  of  actual  events. 

The  patient  lives  in  constant  fear  and  excitement,  and  scarcely  trusts 
herself  to  go  to  sleep.  Morphine  and  bromide  of  potassium  bring  quiet,  but  are 
soon  refused,  for  the  patient  becomes  suspicious  of  the  physician.  June  12, 
1882,  the  patient  was  sent  to  an  insane  asylum  near  her  home  as  probably 
incui'able. 


390  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Siib.sidiari/  Forms  of  PcrscciitDrii  I'araiioia. 

The  disease-picture  of  the  typic  form  of  paranoia  contains  clin- 
ical features  worthy  of  note:  i.e.,  the  delusions  and  errors  of  the 
senses  have  peculiar  colorings  and  contents  due  to  special  etiologic 
factors.  This  is  true  of  cases  developed  upon  the  hasis  of  the  con- 
stitutional neuroses,  or  as  a  result  of  the  influence  of  oro-auie  diseases, 
in  so  far  ns  tlie  somatic  processes  give  n  i^artieulai-  cDnfont  to  tlie 
delusions  arising  in  the  unconscious  psychic  spliciH';  or  Ijucause  the 
causal  sensations,  etc.,  are  incorrectly  interpreted  by  the  paranoiac 
consciousness. 

These  disease-pictures  of  neurotic  paranoia  are  described  under 
the  neuroses.  Besides,  there  are  the  following  disease-pictures  to  be 
described : — 

Sexual  Paranoia,  icitli  its  Clinical  Pictures. 

The  foundation  of  these  forms  of  paranoia  is  a  functional  or 
organic  genital  disease  as  the  exciting  cause  of  the  mental  disease. 
In  men  this  is  almost  exclusively  abuse  of  the  sexual  organs  in  mas- 
turbation; less  frequenth',  forced  sexual  abstinence  will;  excessive 
libido;  and  least  frequently  chronic  gonorrheal  inlianunalion  of  tbe 
posterior  urethra  —  all  of  which  injurious  influences  may  induce 
sexual  neurasthenia,  and  later  general  nervous  weakness,  which  then 
act  as  the  exciting  causes.  Neurasthenic  paranoia  (masturbatory) 
will  be  described  later.  The  same  causes  are  eifectual  in  women;  or 
there  may  be  anomalies  of  position  of  the  uterus  or  other  genital 
diseases  that  irritate  the  nervous  system,  and  become  effectual 
through  the  induction  of  neurasthenia.  The  false  interpretations  of 
local  genital  and  neurasthenic  troubles  are  similar  in  both  sexes 
(vide  infra).  In  women  also  there  are  pollutions  (thought  to  be 
nocturnal  sexual  attacks),  hallucinations  of  smell,  delusions  of  phys- 
ical persecution,  etc.  There  are  also  cases  of  sexual  paranoia  in 
women  (very  frequently  in  the  climacteric),  in  which  the  genital  dis- 
ease without  the  connecting  link  of  spinal  irritation  gives  rise  directly 
to  deliria  and  hallucinations  of  a  sexual  persecutory  character.  Such 
patients  notice  that  men  approach  them,  because  they  are  taken  for 
prostitutes.  Such  an  opinion  about  them  has  been  spread  to  injure 
them.  From  this  arises  the  bad  treatment  by  the  family,  friends,  etc. 
Later  the  patients  hear  at  night  rappings  on  the  window  and  immoral 
proposals.  Even  in  sermons  such  obscene  ideas  are  discovered.  Still 
later,  hallucinations  of  hearing  develop  (of  being  a  liarlot.  syphilitic, 
a  murderess  of  babes,  of  having  induced  abortion).  Such  false  per- 
ceptions are  further  elaborated  (by  combination);  for  example,  she 


PSYCHIC  DEGENERATIONS.  391 

is  to  be  forced  into  a  house  of  prostitution.  As  reactions,  there  are 
profound  depression,  occasionally  even  suicide,  delusions  of  preg- 
nancy, and  ail  Icinds  of  attempts  to  save  threatened  sexual  honor 
(tampons  placed  in  the  vagina,  etc.).  In  all  such  cases  transforma- 
tion of  the  persecutory  delirium  to  an  erotomaniac  expansive  state 
may  take  place,  and  thus  there  are  clinical  transitions  to  hysteric 
paranoia. 

Case  24. — Paranoia  sexualis. 

S.,  aged  35,  single,  domestic,  was  admitted  to  the  mental  clinic  at  Gratz, 
September  4,  188Ö.  She  herself  sought  admission  to  have  help  against  her 
persecutors.  The  patient  comes  of  a  drimken  father.  She  has  never  been 
sick;  menses  at  15;  was  passionate;  had  had  many  lovers;  had  borne  eight 
times,  the  last  in  1873.  Since  then  she  had  often  had  uterine  troubles  and 
irregular  menses.  She  had  given  up  sexual  congress  since  1877.  Three  years 
ago,  while  on  a  journey  with  her  employers,  she  heard  voices — always  the 
same  unfamiliar  masculine  voices.  She  seemed  to  hear  them  through  a  speak- 
ing tube.  She  was  told  she  had  murdered  her  children,  was  a  prostitute, 
aflfected  with  a  foul  disease,  a  thief,  that  she  deserved  to  be  beaten  and  thrown 
in  the  water.  Her  whole  life  and  all  her  love-affairs  were  criticised.  Patient 
was  astounded,  and  assumed  that  her  former  confessor  had  told  her  confes- 
sions. She  then  noticed  how  everybody  despised  her  and  spat  in  her  presence. 
She  left  her  place  and  tried  another,  but  she  was  persecuted  by  the  same 
voices  and  contempt  everywhere. 

This  persecution  made  the  patient  sick  and  miserable.  Female  voices 
were  added,  always  with  the  same  persecutory  sexual  content.  She  was^ 
allowed  no  rest  at  night,  and  her  greatest  secrets  were  discovered.  In  1878 
she  noticed  that  her  persecutors  knew  her  thoughts,  and  answers  were  made 
to  what  she  might  be  thinking.  All  her  thoughts,  desires,  and  acts  were 
criticised  and  ridiculed.  It  could  not  be  endured.  She  was  told  that  she  was 
crazy,  but  she  thought  it  was  due  to  persecution,  and  not  to  disease.  She 
was  called  harlot  and  murderess  of  children.  Often  she  was  tired  and  de- 
pressed by  this.  During  the  last  few  months  she  had  been  troubled  by  foul 
odors,  Avhich  early  in  the  beginning  of  the  persecution  had  troubled  her.  To 
escape  her  unknown  persecutors  during  the  last  few  months  the  patient  had 
wandered  about  in  the  country  imtil  she  was  devoid  of  all  means,  and  she 
came  to  the  hospital  in  Gratz  for  help  and  protection. 

The  patient  has  a  rhombocephalic  cranium,  and  is  of  exquisite  neuropathic 
appearance.  The  foreign  type  of  her  personality  derived  from  the  proletariat; 
her  fine  features,  white  and  delicate  skin,  and  swimming,  genuinely  nervous 
eyes  are  remarkable. 

The  uterus  is  of  the  size  of  an  apple,  and  almost  immovable  as  a  result 
of  adhesions,  which  fix  it  on  both  sides.  The  cervix  is  hard,  swollen,  enlarged, 
and  sensitive  to  jDressure. 

The  patient  presents  no  symptoms  of  neurasthenia  or  hysteria,  though 
there  are  sensations  in  the  area  of  distribution  of  the  pudendo-sacral  plexus. 

She  compares  these  sensations  to  worms  which  wriggle  about  in  the 
pelvis.    Some  days  the  patient  is  free  from  voices  and  thinks  she  has  escaped 


392  SPECIAL  PATHOLOGY  AND  THEEAPY  OF  INSANITY. 

her  persecutors.  Then  tlie  voices  return,  and  with  them  the  old  distress. 
Potassium  bromide  and  injections  of  morphine  haA'e  a  quieting  effect  and 
lessen  the  voices.  \\'ith  time,  the  voices  seem  to  arise  in  tlie  abdomen,  where 
the  patient  has  abnormal  sensations.  Tliere  is  a  sensation  there  as  if  the 
abdomen  contained  a  cat.  All  possible  obscenities  and  coarseness  are  cast 
upon  her.  Since  the  disease  remained  stationary  for  months,  the  patient  was 
sent  to  an  asylum  for  the  chronic  insane. 

A  remarkable  variety  of  sexual  persecutory  paranoia  is  delusions 
of  jealousy  in  paranoiac  women. 

With  Kräpelin,  I  find  this  principally  in  the  climacteric  and 
having  a  combinational  manner  of  origin.  There  is  a  short  period  of 
incubation  with  an  irritable  emotional  state  based  upon  the  feeling 
of  being  neglected  by  the  husband,  and  in  part  upon  consciousness  of 
the  disappearance  of  physical  charms,  which,  with  increasing  mis- 
trust, leads  up  to  the  development  of  delusions. 

The  suspicion  of  marital  infidelity  on  the  part  of  the  husband  is 
confirmed  by  harmless  acts  (conversation  of  the  husband  with  neigh- 
bors' wives,  remaining  out  longer  the  same  evening,  indifferent  state- 
ments about  others,  etc.).  The  suspicion  becomes  certainty  when  the 
injured  wife  catches  her  husband  in  nightly  rendezvous  with  girls. 
His  indifference  goes  so  far  that  he  brings  women  home  with  him  at 
night;  rappings  on  the  windows,  cracking  in  partitions  and  corridors 
of  rooms  are  proofs;  signs  are  made  to  the  object  of  his  love  by 
coughing.  Finally  the  patient  hears  women  at  night  in  the  room. 
It  is  remarkable  that  she  does  not  see  the  women,  but  she  feels  it  in 
herself  (awakening  of  lustful  sensations  as  a  result  of  ideas — feelings 
of  pollution  as  soon  as  the  husband  is  with  these  women).  Her  ac- 
quaintances pity  the  neglected  wife,  but  are  ashamed  of  her  never- 
theless. The  joy  of  the  house  is  destroyed.  In  accordance  with  her 
character,  the  patient  becomes  either  resigned  or  furious.  She  fears 
for  her  life  and  anticipates  the  worst  on  the  part  of  her  husband.  As 
a  result  of  supposed  necessity,  not  infrequently  there  is  violence  or 
attempts  to  poison  the  husband.  Under  some  circumstances  there 
are  attempts  as  a  result  of  revenge. 

Case  25. — Paranoia  sexualis  (delusions  of  jealousy). 

W.,  official's  wife,  aged  43.  Admitted  December  21,  1880.  She  comes  of 
an  imbecile,  psychopathic  mother  whose  mother  was  insane.  From  childhood, 
the  patient  was  neuropathic,  suffered  with  migraine,  and  as  a  child  had  at 
times  visual  hallucinations.  She  was  married  at  23,  had  a  child  at  the  age  of 
25,  and  a  miscarrige  at  the  age  of  26.  Thereafter  there  was  chronic  nephritis. 
Since  then  she  has  been  irritable,  quarrelsome  and  jealous  of  her  husband 
■without  amy  reason.  In  the  beginning  of  1880  the  climacteric  began  (scjjnty, 
irregular  menses,  bad  sleep,  vertigo,  and  feeling  of  fullness  in  the  head).    The 


PSYCHIC  DEGENERATIONS.  393 

patient  became  extremely  irritable,  suspicious  of  those  around  her,  and  ac- 
cused her  husband  of  relations  with  an  old  sick  lady;  she  became  extremely 
excited,  raved  about  him  and  about  various  neighbors'  wives  whom  she 
brought  into  relation  with  her  delusions  of  jealousy.  Auditory  and  visual 
hallucinations  aided  the  delusion. 

At  night  she  heard  whispering  in  her  bedroom  and  heavy  breathing  and 
sighing,  and  was  thus  excited;  had  pollutions  and  became  convinced  that  her 
husband  was  with  other  women.  Gradually  pollutions  occurred  in  the  day- 
time, from  which  the  patient  drew  the  same  conclusions.  Frequently  there 
were  also  olfactory  hallucinations  of  foul  odors.  Increasing  excitement,  pub- 
lic scandal,  threatening  of  her  husband  and  his  supposed  mistresses,  in  which 
the  patient  was  furious,  made  it  necessary  to  send  her  to  the  asylum.  Of  late, 
delusions  of  persecution  had  taken  on  a  wide  range.  The  patient  thought  not 
only  that  she  was  sexually  deceived,  but  also  that  her  life  was  threatened, 
that  her  husband  was  in  a  plot  with  his  mistresses  to  kill  her  with  poison. 
She  noticed  that  she  was  looked  on  with  shame  and  contempt. 

In  the  asylum,  at  first  the  patient  felt  herself  to  be  an  injured  and  perse- 
cuted wife.  She  demanded  her  discharge,  protection  of  her  relatives,  and  im- 
prisonment of  her  husband,  and  regarded  her  delusions  of  jealousy  and  perse- 
cution as  perfectly  justified.  In  the  course  of  the  year  1881  these  delusions 
retreated  into  the  background  and  in  their  place  there  was  the  picture  of 
chronic  nymphomania. 

She  became  coquettish,  erotic,  and  approached  the  physicians  and  ac- 
cused them  of  taking  away  her  senses  with  chloroform.  She  pursued  the 
physicians  occasionally  with  invitations,  took  them  for  princes,  and  furiously 
demanded  embraces.  The  following  year  the  patient  presented  a  state  of 
chronic  nymphomania  with  constantly  increasing  signs  of  mental  weakness. 
The  genital  findings  were  uterine  infarct,  and  hypertrophic  cervix  with  a 
fissure. 

Delusions  of  jealousy  in  men  belong,  for  the  most  part,  to  alco- 
holism. Outside  of  alcoholism,  I  have  found  it  occasionally  in  tainted 
individuals  that  were  always  inclined  to  jealousy,  mentally  of  limited 
endowment  and  of  weak  virility,  though  at  the  same  time,  in  some 
cases,  passionate  and  incapable  of  sexual  satisfaction. 

This  last  condition  (relative  psychic  impotence),  whether  it  be 
due  to  frigidity  of  the  wife  or  absence  of  lustful  feeling  in  the  hus- 
band, plays  an  important  part  in  the  development  of  the  delusion. 
At  first  this  arises  by  way  of  combination :  accidental,  but,  frequent 
visits  of  gentlemen  in  the  house  are  thought  to  be  for  the  wife.  When 
she  clears  her  throat  it  is  a  sign  given  to  her  lover  hidden  near  by. 
Every  noise  at  night  is  interpreted  in  the  same  sense.  There  is  in- 
creasing avoidance  of  the  wife,  and  brutal  treatment  of  her  that  may 
go  to  actual  violence.  Auditory  and  sometimes  visual  illusions  help 
on  the  delusion.  People  in  the  street  cast  insulting  glances  or  ges- 
tures, indicating  the  act  of  "  putting  on  the  horns."  The  children  are 
alienated  from  the  father  by  the  wife;  they  do  not  resemble  him — 


304  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

therefore  they  arc  not  liis  children.  In  the  course  of  fnrtlier  develop- 
ment there  are  often  delusions  of  general  persecution — delusions  of 
heing  robhed,  in  that  the  unfaithful  wife  gives  money  and  property  to 
her  lovers;  delusions  of  poisoning.  Not  infrequently  there  are  grave 
acts  of  violence  toAvard  the  wife  and  her  supposed  lovers. 

Case  26. — Paranoia  scxualis  (delusions  of  jealousy  in  a  hus- 
band). 

P.,  aged  47.  Admitted,  November  29,  1S7S.  Suboffitial,  said  to  be  un- 
tainted; a.  moral,  industrioii.s  man  of  siiuill  iiiciilal  cinliiw  niciit .  who  lias 
always  been  passionate;  father  of  several  cliildrcn.  living  in  correct  marital 
relations.  In  1877  he  received  a  severe  injury  of  the  head;  he  Avas  attacked, 
thrown  on  the  pavement,  and  struck  with  a  loaded  cane.  Besides  slight  in- 
juries there  "was  a  severe  tranma  with  depression  of  the  left  temporal  bone. 
He  was  unconscious  for  a  long  time,  and  confined  to  the  bed  several  weeks. 

In  his  convalescence  he  seemed  changed  mentally,  irritable,  and  weakened. 
He  became  abnormally  passionate,  then  suspicious,  and  expressed  ideas  that 
liis  wife  was  not  true  to  him.  "When  his  wife  cleared  her  throat  or  sighed,  he 
became. excited  and  violent,  because  he  thought  her  lover  was  thinking  of  her. 

Gentlemen  visited  the  house  only  on  account  of  his  wife.  Occasionally 
he  stated  that  she  had  her  lovers  in  the  house,  committed  immoral  acts  with 
them,  and  planned  to  kill  him.  On  account  of  these  ideas,  he  Avas  joked  and 
laughed  at  by  his  acquaintances.  He  felt  hurt  at  this,  and  his  condition  grew 
worse.  He  stated  that  his  wife  took  fuel  and  food  to  her  lovers.  Every  noise 
he  heard  at  night  indicated  to  him  that  some  one  was  stealing  to  his  wife. 
He  heard  doors  slightly  open  and  low  voices,  became  more  and  more  excited 
and  brutal,  and  threatened  to  shoot  his  wife.  In  November,  1878,  he  seemed 
about  to  carry  out  his  threat  and  was  arrested. 

In  the  asylum  he  held  to  his  delusions.  His  wife  wa.s  remarkably  friendly 
with  men  who  came  to  visit  them.  They  came  very  frequently  and  wdth  all 
sorts  of  excuses.  He  noticed  the  disappearance  of  fuel  and  of  food.  If  he 
spoke  to  his  wife  about  this,  she  was  embarrassed  and  wept.  On  evenings 
she  liked  to  find  something  to  do  outside  the  house.  The  patient  is  convinced 
that  she  has  several  lovers.  On  several  occasions  she  came  home  with  her 
toilet  quite  deranged.  He  did  not  wish  to  shoot  her,  but  to  threaten  her  in 
order  to  make  her  change  her  scandalous  conduct. 

The  patient  is  without  signs  of  degeneration,  and  without  any  conse- 
quences due  to  his  head  injury.  Mentallj'^  weak.  In  the  institution  the  delu- 
sions of  jealousy  retired  into  the  background,  without,  however,  being  com- 
pletely corrected.     On  December  28,  1878,  he  was  discharged  improved. 

2.  Querulous  Insanilij  u'ilh  Mania  for  Lairsuils. 

This  differs  from  the  foregoing  form  in  that,  in  the  opinion  of 
the  patient;,  the  interests  endangered  are  legal  rather  than  vital,  and 
the  starting-point  of  the  delusion  lies  in  actual,  not  imaginary, 
events;  while  the  patient  soon  takes  the  active  role  of  the  persecutor, 
and  not  that  of  the  persecuted.    However,  not  infrequently  in  this 


PSYCHIC  DEGENERATIONS.  395 

form  of  qiioruloiis  insanity  the  delusions  of  the  ordinary  form  o£ 
paranoia  occur  episodically,  and  sometimes  it  takes  its  origin  in  these. 
Essen tialh^,  however,  it  is  a  paranoia  combinaloria. 

Individuals  affected  Avith  querulous  insanity  are  tainted,  usually 
hereditarily,  with  somatic  signs  of  degeneration  (anomalies  of  the 
cranivmi),  and  early  and  constantly  affected  with  psychic  anomalies 
and  defects.  The  clearest  and  most  important  defect  is  ethic  jjer- 
version,  which,  in  spite  of  consciousness  of  the  outward  forms  of 
justice,  never  permits  a  profound  moral  conception  of  right.  For 
them  this  gains  a  formal  value  only  as  a  legal  weapon  for  the  at- 
tainment of  egotistic  ohjects. 

Out  of  ethic  defect  soon  arises  colossal  egotism  which  miscon- 
ceives the  rights  of  others,  which  tends  constantly  to  the  assertion  of 
personal  rights,  and  reacts  to  an  actual  or  supposed  injury  to  personal 
interests  in  the  most  violent  way. 

The  candidates  for  this  disease  early  attract  attention  by  their 
selfishness,  irritability,  their  brutal  demands  for  justice,  their  infinite 
overestimation  of  self;  and  by  reason  of  these  evil  characteristics 
they  are  constantly  in  conflict  with  others.  As  a  rule,  the  intellectual 
endowment  is  below  the  average;  but,  even  when  there  are  certain 
mental  capabilities  more  or  less  noticeable,  a  distortion  of  logic  is 
never  missed,  which,  in  spite  of  all  apparent  sharpness  of  judgment, 
shows  important  defects,  which  develop  only  too  easily  pettifogging 
legal  tendencies.  Frequently,  too,  there  is  defect  in  the  power  of 
reproduction,  and  facts  reappear  in  consciousness  in  a  distorted  light- 
Numerous  persons  of  this  kind  remain  at  this  degree  of  origiral 
anomaly  of  character  and  become  a  burden  to  their  associates  on 
account  of  their  tendency  to  indulge  in  pettifogging  legal  processes. 
In  many  there  is  formal  pleasure  in  lawsuits. 

The  accidental  cause  of  the  actual  disease  may  be  any  lawsuit 
in  which  the  individual  has  been  defeated;  or  it  may  be  the  mere 
rejection  of  his  assumed  legal  rights,  which  are,  in  reality,  audacious 
assumptions.  JSTot  as  result  of  a  lively  sense  of  justice,  as  was  fre- 
quently supposed,  but  out  of  a  laclv  of  the  sense  of  justice,  dependent 
upon  their  intellectual  perversion,  such  individuals  fall  into  a  pas- 
sionate state  of  feeling  as  a  result  of  the  presumed  injur}^  to  them- 
selves. They  quickly  lose  their  reason,  and  have  only  one  purpose  in 
view — the  restoration  of  their  presumed  injured  rights.  Occupation, 
family  affairs,  and  the  welfare  of  their  home  take  a  position  subordi- 
nate to  this  duty. 

After  a  time  they  recover  from  the  chagrin  which  they  at  first 
suffer,  brooding  over  their  position  and  out  of  sorts  with  the  world. 


396  SPECIAL  PATHOLOGY  AND  THEEAPY  OF  INSANITY. 

Putting  faith  in  their  abnormal  overestimate  of  self  and  their  own 
po^yer,  and  without  trust  in  law3'ers  owing  to  their  abnormal  sus- 
picions, during  lliis  time  of  brooding  theydevote  themselves  to  the 
acquirement  of  knowledge  of  the  law  and  legal  procedure.  Armed 
with  these  weapons  they  at  last  besiege  the  courts,  write  accusations, 
and  make  appeals  wherever  possible. 

Q'here  is  still  a  certain  remnant  of  clearness  of  thought,  and 
the  passionate  excitement  is  controlled  in  a  measure  and  speech  kept 
within  bounds.  "With  the  repetition  of  lack  of  success  in  their 
eiforts,  and  the  consequent  disappointment,  they  become  more  and 
more  bitter,  have  less  insight,  and  lose  what  remains  of  clearness 
of  thought.  The  state,  which  up  to  this  time  might  be  regarded 
as  passion  by  the  psychologic  observer,  becomes  more  and  more  clearly 
mental  disease,  devoid  of  insight,  jiTdgment,  and  reason.  Instead  of 
recognizing  that  their  suit  was  unsuccessful  because  it  was  unjust, 
these  patients,  owing  to  their  mistrust,  seek  the  cause  of  their  failure 
in  partiality  and  venality  of  the  judges ;  and  in  harmless  events  they 
find  proofs  for  this  conviction,  which  becomes  more  and  more  fixed. 
Now  the  last  restraints  disappear.  Their  constantly  more  voluminous 
recriminations,  requests,  and  denunciations  are  filled  with  invectives 
and  insults  to  ofiicials,  which  attract  the  attention  of  the  law,  an 
event  which  only  serves  to  intensify  the  passionate  state  of  the  pa- 
tients. 

They  now  look  upon  themselves  as  martyrs  and  dupes  of  law; 
all  legal  procedure  was  only  a  comedy  of  justice.  With  insane  ob- 
stinacy, pettifogging  logic,  and  shameless  brutality,  these  individuals 
now  oppose  not  only  justice,  but  the  law  which  has  given  judgment 
against  them.  They  refuse  to  pay  fines,  indemnities,  taxes.  They 
attack  the  officers  of  the  law  and  call  the  judges  of  the  State  thieves, 
scoundrels,  and  perjurers.  They  feel  that  they  are  in  the  state  of 
war  against  suffering  justice  and  its  evil  interpreters,  as  champions 
of  right  and  morality,  as  martyrs  of  brutal  force.  Sometimes  they 
become  protectors  and  advocates  of  other  oppressed  persons,  like  the 
querulous  individual  examined  by  Büchner,  who,  with  others  of  like 
mind,  got  up  a  union  of  the  oppressed, — i.e.,  for  their  protection, — 
of  those  who  had  been  treated  badly  by  the  law,  and  gave  notice  of 
the  existence  of  this  society  to  the  king.  Usually,  for  a  long  time 
such  patients  are  misunderstood  by  the  laity  and  punished;  for,  in 
spite  of  the  absence  of  insight  into  the  foolishness  and  irrelevancy  of 
their  manner  of  action,  they  possess  a  remarkable  amount  of  dialectic 
power  and  knowledge  of  law,  and  are  excellent  advocates  of  their 
affair,  which  unfortunately  is  of  an  insane  kind.    Hardly  have  they 


PSYCHIC  DEGENERATIONS.  397 

been  piinislicd  than  they  commit  again  the  same  misdem-eanors, 
which  are,  for  the  most  part,  insults  to  olllcials,  and  therefore  they 
seem  to  he  confirmed  criminals,  deserving  further  aggravated  pun- 
ishment; hut  their  illogical  unyielding  conduct  is  only  the  natural 
result  of  their  disease. 

Thus  the  necessary  and  beneficent  appointment  of  a  g^uardJan  and 
commitment  to  an  asylum  take  place  unfortunately  only  after  they 
have  used  up  their  property,  insulted  the  courts,  disturbed  public 
order,  and  destroyed  public  respect  for  the  law.  They  may  have 
communicated  their  delusions  to  their  relatives,  or  even  revenged 
themselves  in  blood  on  their  enemies. 

Case  27. — Querulous  insanity;  later  delusions  of  poisoning  and 
persecution. 

Mrs.  S.,  aged  43,  wife  of  a  shoemaker,  legally  divorced.  Her  father  was 
insane.  Even  as  a  child  she  was  peculiar  for  her  self-assertiveness  and  her 
unusually  developed  feeling  of  a  sense  of  justice.  Twenty-three  years  ago  she 
was  married  without  inclination,  which  after  a  short  time  led  to  divorce,  it  is 
said  in  part  because  at  night  she  was  troubled  with  incontinence,  a  habit  which 
troubled  her  until  her  first  child  was  born,  and  which  was  inherited  by  this 
daughter,  the  latter  suffering  with  it  until  the  time  of  puberty. 

Mrs.  S.,  later,  besides  showing  great  irritability  and  inclination  to  mix 
up  in  other  peoples'  affairs,  presented  nothing  remarkable.  In  the  beginning 
of  the  70's  her  father  and  brother  died.  She  was  not  satisfied  with  what  she 
inherited,  and  raised  the  suspicion  that  her  relatives  and  the  court  had  de- 
prived her  of  six  thousand  gulden.  This  prejudice  is  said  to  have  left  her  no 
peace.  She  bought  legal  books  and  gave  herself  up  to  studying  them.  By 
devious  ways  she  was  able  to  get  knowledge  and  copies  of  papers  relating  to 
succession  and  family  documents.  Her  suppositions  Avere  not  erroneous.  She 
became  certain  that  at  the  time  of  the  inheritance  money  had  been  misap- 
propriated, signatures  had  been  forged,  and  when  she  had  imited  all  her 
proofs  she  addressed  a  complaint  to  the  court.  Unfortunately  her  efforts 
were  unsuccessful.  As  she  noticed  later,  at  the  first  examination  very  little 
interest  was  shown,  and  they  went  to  Avork  with  partiality,  setting  down  in- 
completely the  proofs,  not  adding  the  necessary  paragraphs  and  making  it 
difficult  for  her  to  bring  proofs,  so  that  she  did  not  succeed.  She  noticed  that 
the  lower  court  was  interested  in  the  affair,  made  an  appeal,  the  affair  was 
sent  back,  and  she  then  made  a  more  violent  application.  AneAV  she  gave  her- 
self to  the  study  of  the  law,  because  she  noticed  that  the  lawyers  were  sly 
foxes  and  deceivers  and  AA'ere  worth  nothing;  but  since  she  found  partiality 
and  dishonesty  everywhere  she  was  unable  to  obtain  justice,  although  she  had 
employed  all  means. 

Her  language  became  more  and  more  haughty  and  insolent.  She  felt 
on  account  of  her  great  knowledge  of  the  laAV  and  her  sense  of  justice 
that  she  was  called  to  cause  the  laAvs  to  be  applied  and  to  uncoA^er  the  im- 
postors. As  a  result  of  such  an  attempt  she  found  herself  for  the  first  time 
on  February  13,  1877,  before  a  court  on  account  of  insult  to  officers  of  the  laAv. 
In  spite  of  her  astonishing  persuasive  poAver  and  brilliant  defense,  she  was 


39S  SPECIAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

sentenced  to  punislmicnt.  In  spite  of  this  she  oontiniK'd  to  make  demands 
and  institute  suits. 

On  August  13,  1S77,  slie  was  called  betöre  tlie  court  to  answer  to  renewed 
ollense  to  public  oflicers. 

She  appeared  Avith  a  large  bundle  of  papers,  answered  every  question  ad- 
dressed toher  partly  whh  paragraphs  taken  from  the  code  of  legal  procedure, 
the  contents  of  which  were  as  familiar  to  her  as  the  Lord's  Prayer,  partly  by 
extracts  from  her  papers,  even  w  lien  tiiey  accidentally  were  in  opposition  to 
that  wliich  she  wished  to  prove. 

She  maintained  that  the  persons  who  had  been  insulted  by  her  were  quite 
deserving  of  it,  and  that  she  would  not  change  one  iota  of  it.  Mrs.  S.,  de- 
claiming standing  and  using  a  chair  as  a  speaker's  desk,  said:  "I  shall  address 
myself  to  the  Minister  of  Justice  to  communicate  to  him  the  intrigues  that 
are  carried  on  against  me;  and  in  case  he  does  not  give  me  justice,  I  shall 
appeal  to  the  Supreme  Court,  which  I  hope  will  xmcover  the  deception;  or 
perhaps  it  is  thought  that  I  do  not  know  the  way  to  the  Supreme  Court.  I 
demand  my  rights,  nothing  else,  and  I  shall  know  how  to  obtain  everything 
that  has  been  kept  from  me  in  the  most  shameless  manner."  With  a  louder 
voice — "I  shall  not  rest,  and  finally  I  shall  apply  to  the  Emperor."  IMedical 
examination  during  the  course  of  the  trial  showed  Mrs.  S.  to  be  suffering  with 
querulous  insanity.  During  her  speech  slie  became  greatly  excited  and  had 
only  partial  control  of  herself.  Suppressed  ironic  exclamations  escaped  from 
her,  such  as:  "And  the  court  medical  examiner  says  that?  Another  plot, 
nothing  but  this;    /  insane!" 

"When  the  opinion  was  finished,  she  said,  in  a  most  indignant  manner, 
''It's  ridiculous,"  and  left  the  room,  bowing. 

Mrs.  S.  was  declared  not  guilty  on  account  of  irresponsil)ility.  She  con- 
tinued in  lier  querulous  conduct.  A  gross  insult  to  her  relatives  in  the  open 
street  led  to  her  arrest  and  commitment  to  an  asylum. 

She  entered  the  asyhun  with  a  loud  protest  against  being  robbed  of  her 
freedom,  and  expressed  herself  in  the  worst  insults  toward  representatives  of 
the  law,  lawyers,  etc.,  and  said  that  the  physician,  on  account  of  his  opinion, 
was  a  party  to  the  plot  against  her.  She  maintains  her  imposing  attitude, 
insists  upon  her  rights,  writes  numerous  memorials  in  which  she  mixes  para- 
graphs from  the  criminal  and  legal  codes  and  code  of  procedure,  etc.;  and 
admiring  herself,  she  breaks  forth  with  the  words:  "Oh,  I  am  well  up  on  these 
points;  there  is  nothing  to  be  reconsidered,  even  in  the  article  in  the  news- 
paper about  my  defense.  It  was  recognized  that  I  was  very  well  up  on  the 
code  of  criminal  procedure.  The  proofs  lighted  up  electrically  in  my  mind;  I 
wrote  an  appeal  that  was  astonishing.  In  the  trial  it  seemed  as  if  the  court 
was  made  up  of  accused,  and  I  was  the  real  court.  They  should  tremble  be- 
fore me,  these  astute  Tartufes.  In  the  papers  one  can  read  that  in  the  last 
conference  of  Ministers  the  Magistrates  of  G.  were  seriously  handled;  but 
wolves  do  not  eat  each  other." 

She  takes  pleasure  in  the  anticipation  of  her  future  trial,  and  compares 
herself  to  a  genuine  full-blooded  horse  that  storms  and  destroys  all  before 
him.  She  intends  to  attack  the  whole  will  of  her  father,  since  it  was  written 
with  his  own  hand  without  a  notary  and  made  up  without  proper  legal  form. 
That  was  the  reason  why  the  children  had  been  given  but  the  smallest  shares. 
Occupied  with  such  feelings  and  thoughts,  the  patient  went  about  with  the 


PSYCHIC  DEGENERATIONS.  399 

greatest  hauteur.  At  the  same  time  she  intrigued  and  quarreled,  made  her- 
self the  advocate  of  her  fellow-patients,  criticised  the  rules  of  the  house,  which 
she  found  to  be  bad,  and  acted  brutally  and  impertinently  toward  the  officers 
and  servants  of  the  house.  The  extent  of  the  patient's  mental  disturbance,  in 
spite  of  all  dialectic  and  sharpness  of  thought  in  reference  to  the  law,  is 
shown  by  her  great  irritability,  which  even  in  the  asylum  makes  life  with  her 
almost  impossible;  and  by  tlie  slight  cause  necessary  to  produce  an  uncon- 
trolled explosion  of  anger.  On  such  occasions  delusions  of  persecution,  latent 
or  concealed  at  other  times,  were  discovered.  She  thought  an  effort  was  being 
made  to  destroy  her  understanding;    that  poisonous  medicines  were  given  her. 

Mrs.  S.  is  of  medium  height  and  well  preserved.  The  expression  of  the 
face  is  hauglity  and  sly.  The  left  side  of  the  face  is  narrower  than  the  right, 
and  less  actively  innervated.  There  are  no  other  skeletal  anomalies.  The 
vegetative  functions  present  no  disturbance. 

During  the  last  two  years  the  picture  of  querulous  insanity  has  become 
less  and  less  marked,  Avith  greater  prominence  of  delusions  of  persecution 
based  upon  imaginary  threats  against  her  health  and  life:  a  clear  proof  of  the 
inner  relationship  of  these  symptoms.  The  patient  in  her  memorials  to  the 
officers  only  occasionally  uses  her  former  legal  expressions,  but,  on  the  con- 
trary, suspects  those  about  her  of  having  intentions  against  her  life.  She  saw 
those  aioinid  her  give  sigiiilicaiit  glances  of  understanding;  they  coidd  not 
bear  her  look,  which  made  tliem  blush  and  seem  embarrassed.  Accidentally 
she  saw  spots  on  the  tloor,  or  traces  of  poison  poiu-ed  about,  and  took  some  of 
the  nurses  for  former  servants  of  lier  hostile  relatives,  or  for  paid  assassins. 
Gastric  catarrh,  with  which  the  patient  often  suffered,  was  always  a  proof  to 
her  of  poisoning.  At  such  times  food  had  the  taste  of  chalk  and  metal.  As  a 
reaction  there  were  outbursts  of  anger  in  which  the  patient  in  rage  demanded 
justice,  threw  everything  about,  and  was  only  restrained  with  great  trouble. 
In  these  attacks  she  lost  consciousness  and  afterward  knew  nothing  of  what 
had  taken  place  (pathologic  affect  as  a  further  sign  of  the  profound  cerebral 
disease).  At  the  time  of  the  menses  the  patient  was  sometimes  much  excited, 
irritable,  and  troubled  with  migraine  and  paralgic  sensations.  Transferred 
to  a  hospital  for  the  chronic  insane. 

(B)  Expansive  Paeaxoia. 

This  form  is  decidedly  less  frequent  than  the  depressive  perse- 
cutory form.  In  accordance  with  the  content  and  direction  of  the 
delusions,  there  may  be  differentiated :  1.  Inventive,  or  reformatory, 
paranoia.    2.  Eeligious  paranoia.     3.  Erotic  paranoia. 

1.  Inventive  Paranoia. 

The  subjects  of  this  malady  are  always  tainted,  originally  per- 
verse, and  for  the  most  part  of  inferior  mental  endowment,  or  at 
most  only  endowed  in  a  one-sided  way.  The  delusion  of  distinguished 
personality  is  the  nucleus  of  the  Avhole  disease,  affecting  persons  of  in- 
tensified feeling  of  self-importance,  and  in  part  directly  developed  out 
of  this  characteristic.   The  future  delusion  is  latent  in  the  character 


400  SPECIAL  PATHOLOGY  AND  THEEAPY  OF  INSANITY. 

and  in  the  whole  manner  of  thinking.  This  form  of  paranoia  is  essen- 
tially one  of  combination.  The  period  of  incubation  is  very  long,  char- 
acterized by  dreamy  fantastic  existence,  brooding  over  sensations  and 
discoveries,  dreams  of  air-castles  or  future  might  and  greatness,  feel- 
ings of  being  destined  for  something  important,  great  over-estimate 
of  self,  with  tendency  to  a  haughty  personal  bearing  toward  the  vulgar 
crowd.  The  false  ideas  are  concerned  with  brilliant  deeds,  as  poet, 
artist,  discoverer,  social  reformer,  founder  of  new  religions,  etc.  In 
proportion  to  the  mental  endowment  these  ideas  are  silly,  absurd,  or 
they  are  original  and  at  first  sight  surprising;  and,  in  spite  of  all  per- 
versity and  want  of  harmony  in  the  mental  capabilities,  they  give 
evidence  of  certain  mental  powers. 

Tims  it  may  liappen  that  the  public,  devoid  of  good  judgment,  may  take 
the  individual  for  a  genius,  just  as,  on  the  other  hand,  geniuses  are  taken  for 
fools.  Certain  pseudo-geniuses  and  actual  geniuses  have  in  common  the 
originality  of  their  ideas  based  upon  the  peculiarity  of  the  associations  and  an 
inductive  method  of  thinking. 

Hut  by  tlieir  fruits  true  and  false  genius  are  recognized.  The  first  is  a 
milestone  ■which  marks  the  end  of  one  epoch  and  the  inauguration  of  a  new 
one,  showing  light  ahead  for  the  world,  and  the  full  significance  of  his  powers 
are  recognized  and  appreciated  only  by  those  who  come  after.  False  genius 
is  a  caricature  of  actual  genius,  for  it  has  its  external  appearances,  but  not 
its  inner  worth.  In  the  false  genius  the  mental  force,  calmness,  and  con- 
sciousness of  an  end,  of  the  actual  genius,  are  wanting,  and  likewise  all  the 
qualities  that  arise  out  of  the  superior  and  harmonious  development  of  the 
mental  powers.  Though  the  active  thought  of  the  false  genius  be  original 
and  promising,  yet  he  wants  the  power  to  use  them  logically  and  usefully.  At 
most  there  is  the  capability  to  criticise  and  tear  down  what  exists,  but  not 
the  power  to  create. 

There  are  innumerable  false  geniuses  of  this  kind  in  society, 
forever  dissatisfied  with  what  is,  and  constantly  driven  to  attempt  to 
better  the  world.  They  constantly  feel  themselves  unhappy  as  un- 
recognized geniuses.  They  are  often  on  the  very  borderline  of  para- 
noia, and  it  needs  only  special  circumstances — as,  for  example,  times 
of  excitement — to  deprive  them  of  the  remainder  of  their  reason. 
They  come  forth  then  as  discoverers  of  new  social  and  political 
systems  for  the  saving  of  society,  as  the  founders  of  ideal  states, 
or  the  originators  of  new  religious  sects,  etc.  It  is  interesting  to 
observe  how,  at  such  times,  a  fool  makes  not  ten,  but  a  thousand 
fools;  how  whole  sections  of  the  people  are  infected  by  the  original- 
ity and  eccentricities  of  such  crazy  demagogues,  attracted  by  their 
fanatic  zeal,  founded  sometimes  on  hallucinations,  and  their  pre- 
tended divine  inspiration. 


PSYCHIC  DEGENERATIONS.  401 

It  is  remarkaUe  how  often  twisted  and  more  or  less  paranoiac 
individuals,  as  leaders  of  insurrections  and  revolutions  or  founders 
of  sects,  have  brought  unhappiness  upon  themselves  and  their  con- 
verts. This  was  shown  on  the  occasion  of  the  Commune  in  Paris  in 
1871. 

The  ways  and  means  through  which  in  such  individuals  paranoia 
develops  are,  aside  from  the  rare  hallucinatory  source,  the  same  as  in 
other  forms :  false  combination  aided  by  original  perversity  of  logic, 
errors  of  memor}^,  sudden  occurrence  of  primordial  delusions  ("in- 
spirations"). 

The  obstacles  which  such  unfortunates  encounter  among  their 
rational  fellow-beings,  and  their  final  commitment  to  an  asylum,  they 
regard  as  persecution,  but  without  the  development  of  actual  perse- 
cutory delusions.  In  their  delusions  of  grandeur  and  their  original 
weak-minded  perversion  and  want  of  logic  they  regard  these  mani- 
festations of  sound  thinking  simply  as  vexations  created  by  their  op- 
ponents; as  manifestations  of  jealousy  or  rivalry,  or  of  fear  of  their 
remarkable  talents.  In  the  asylum  these  patients  continue  to  elabo- 
rate their  paranoiac  ideas  of  reform;  they  live  only  for  themselves 
and  for  their  dreams  of  the  future,  awaiting  the  moment  when  these 
shall  be  realized.  In  the  course  of  years  the  personality  is  often 
transformed  into  an  individuality  qu^ite  demented,  and  evidences  of 
confusion  and  mental  debility  become  apparent. 

Case  28. — Eeformatory  paranoia. 

Mrs.  E..  aged  48,  wife  of  a  laborer,  a  widow  eight  years,  mother  of  two 
chikiren.  She  comes  of  a  family  said  to  be  untainted.  Her  mother's  sister 
died  insane. 

At  the  age  of  9  the  patient  had  scarlatina,  and  at  13  typhoid.  From 
puberty,  at  the  age  of  13,  rmtil  26  she  was  chlorotic.  Married  at  the  age  of 
26,  her  marriage  was  unhappy,  and  after  the  death  of  her  husband  she  lived 
with  the  guardian  of  her  children.  As  a  child  she  had  high-flown  ideas.  At 
the  age  of  12  she  wished  to  go  into  a  convent  in  order  to  give  the  Christian 
religion  to  the  heathen.  When  at  this  time  she  left  school,  they  wished  to 
make  her  a  teacher  at  once  ( ! ) .  When  she  was  a  young  girl  she  dressed  in  the 
fashions  one  or  two  years  ahead  of  others,  since  she  could  foresee  these.  Since 
1872  she  had  occupied  herself  with  projects  for  the  improA^ement  of  education. 
She  communicated  her  plans  to  her  relatives  and  later  to  officials,  but  nowhere 
did  she  find  recognition.  Since  1882  she  had  noticed  that  the  newspapers  had 
taken  up  her  ideas,  without,  hoAvever,  recognizing  her  as  the  originator  of 
them.  The  same  thing  happened  with  regard  to  innumerable  inventions  which 
no  one  Avould  accept,  and  which  likewise  were  proclaimed  by  others  and 
brought  to  fruition. 

The  patient  was  giA"en  to  drink  (two  to  three  liters  of  beer,  rum,  grog., 
etc.).  In  the  Minter  of  1886-87  she  had  temporarj-  alcoholic  A'isions  (black  dog, 
dead  relatives,  angel,  devil).    In  1887  the  climacteric  occm-red;    a  sexual  per- 

?6 


403  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

secutory  hallucinatory  paranoia  developed,  wliieli,  however,  disappeared  and 
was  latent  until  Easter  of  18S8. 

On  account  of  this  episodic  mental  trmilih".  tlie  patient.  Avas  in  an  asylum 
some  months  after  January,  1888.  This  paranoia  began  with  voices  whieli  told 
her  that  she  nuist  be  careful  in  order  that  slie  might  become  better.  She  was 
insulted,  called  a  soldier's  whore,  a  beast,  and  she  was  reproached  willi  nnl 
properly  educating  her  children. 

Later  siie  lieard  her  own  conscious  thoughts  expressed.  She  smelled 
incense,  ether,  and  therefore  thought  that  some  one  wislied  to  narcotize  her. 
lood  in  the  restaurants  tasted  strajige,  and  voices  spoke  of  poisoning.  She 
felt  peculiar  pricking  in  her  body,  an  electric  rain  fell  on  her,  and  she  was 
made  to  cough  and  have  palpitation  of  the  licaii.  Often  she  had  dreams  of 
flying,  of  hovering,  and  of  having  coitus.  In  tlie  fall  of  1888  everything  dis- 
appeared, but  the  patient  never  had  any  insight  into  this  episode  of  her 
malady. 

She  now  again  occupied  herself  with  projects  for  the  ]ia[>])iness  and  bet- 
tering of  the  Avorld.  She  felt  an  inner  impulse  to  this,  and  new  sublime 
thoughts  came  to  her  as  inspiration. 

In  December,  1889,  the  pa.tient  was  again  placed  in  the  asylum  on  account 
of  a  pathologic  state  of  intoxication.  Her  expansive  paranoia  had  remained 
unchanged.  At  this  time  the  patient  Avas  entirely  occupied  with  her  social 
projects.  She  felt  in  herself  impulse  to  speak  to  the  people,  and  that  she  was 
a.  reformer  and  must  mount  on  the  barricades.  She  wished  to  restore  the 
fundamental  religion,  and  then  there  would  be  no  more  religious  war  and  no 
race  hatred.  She  wished  to  remove  poverty  and  misery  from  the  world  by 
destroying  money.  "Why  do  Ave  need  money;  all  evil  springs  from  it.  If 
money  did  not  exist  there  Avould  be  no  taxes.  Taxes  make  life  harder;  Avhat 
Ave  eat  is  taxes." 

She  claims  to  have  developed  ideas  in  an  article  entitled  "The  World 
\^'ithout  Money."  The  manuscript  had  disappeared  one  day.  Evidently  the 
editor  of  a  certain  paper  had  illegally  possessed  himself  of  it,  for  one  day  she 
read  lier  article  in  this  paper.  It  Avas  the  same  article,  but  Avith  other  ideas; 
as,  for  example,  the  "certificate  of  capacity,"  Avhich  AA'as  her  Avork. 

She  Avished  to  destroy  monarchy,  and  Avas  convinced  that,  if  her  ideas 
could  be  brought  before  monarehs,  they  themselves  Avould  abdicate.  She 
Avished  also  to  overcome  disease  by  remoA'ing  physicians,  since  they  Avere 
ahvays  creating  nsAV  diseases,  and  thus  their  number  Avas  constantly  increasing. 

She  would  introduce  ncAV  machines;  for  example,  one  from  which 
clothing  would  come  forth  ready  to  Avear.  She  Avould  also  do  aAvay  Avith  the 
armj'.  Already  she  had  once  morally  forced  the  soldiers  to  leave  the  exercise 
ground  by  looking  at  them  Avith  contempt. 

She  felt  called  to  give  lectures  in  order  to  Avin  the  people  from  their 
ideas;  her  great  ideas  come  to  her  often  like  an  inspiration,  and  she  often 
hears  them  like  a  voice.  At  such  times  she  feels  herself  divine,  and  she  could, 
if  necessary,  conquer  the  Avorld. 

In  the  institution  the  patient  occupies  herself,  proudly  separating  herself 
from  the  others,  with  the  elaboration  of  her  social  problem,  and  writing  out 
her  thoughts  as  to  how  the  social  question  is  to  be  solved.  These  consist 
essentially  in  the  destruction  of  all  existing  institutions  (state,  marriage,  re- 
ligion, etc.),  Avithout  presenting  any  positive  substitute.     "Everybody  should 


PSYCHIC  DEGENERATIONS.  403 

govern  himself;  an  educated  people  governs  itself.  It  is  time  to  strike  the 
fetters  from  mankind.  Free  love  must  take  the  place  of  marriage;  then 
there  will  be  no  longer  any  unhappy  marriage.  In  place  of  the  church  must 
come  the  kitchen,  and,  in  place  of  masses,  eating." 

She  poses  as  the  prophet  of  a  new  order  of  things.  "When  sovereigns 
and  rulers  take  up  my  ideas,  then  the  time  will  come;  but  it  will  be  too  late, 
and  1  shall  remain  deaf  to  their  entreaties  to  save  society." 

Her  future  religion  is  the  religion  of  Nature;  her  only  God,  the  earth. 
Here  she  is  imprisoned  because  her  superiority  is  feared;  but  the  day  of 
reckoning  will  come.  She  will  tear  off  the  mask  of  hypocrites;  a  new  order 
of  things  in  the  world  will  be  planned,  and  the  innumerable  unfortunates  who 
are  here  imprisoned  unjustly  as  insane  will  be  free.  The  greatest  fools  are 
without;  the  whole  world  is  crazy.  She  has  prophesied  much  that  has  come 
true  (errors  of  memory).  This  prophecy  will  also  be  fulfilled.  In  a  new 
project  for  freeing  the  world  she  ajjostrophizes  finally  the  lords  of  creation 
and  denies  them  the  right  to  rule  the  world.  This  right  belongs  to  women, 
since  it  is  they  who  bear  children. 

The  patient  has,  Avith  a  seeming  store  of  knowledge  and  reminiscences 
from  reading,  a  certain  talent  in  speaking,  and  with  great  pleasure  and  assur- 
ance she  gives  a  free  lecture  in  the  clinic.  She  defends  her  crazy  ideas  against 
objections  with  seeming  skill. 

The  patient  is  without  signs  of  degeneration,  well  preserved,  and  phys- 
ically sound. 

2.  lielifjious  Paranoia. 

The  previous  life  of  these  patients  shows  a  disposition  to  mental 
disease  in  general  and  especially  to  this  form.  In  many  cases  the 
resulting  disease  is  only  the  development  of  an  excessively  religious 
character  distorted  from  childhood^  and  is  like  an  hypertrophy  of  the 
character. 

Almost  always  the  representatives  of  this  group  of  mental  dis- 
turbance are  originally  weak-mind  edj  whose  limited  powers  are  unable 
to  comprehend  the  ethic  nucleus  of  religion.  It  expresses  itself  in 
the  formal  showy  exterior  of  religious  observances^  and  with  the 
mental  limitation  and  laziness  of  the  weak-minded,  one-sidedly  de- 
votes itself  to  the  fulfillment  of  misunderstood  religious  command- 
ments. Thus  the  one-sidedness  of  their  minds  becomes  more  and 
more  intensified.  These  weak-minded  persons  are  much  influenced 
by  iTjissionaries  and  zealous  priests  in  general,  who  paint  the  miseries 
of  the  Church,  the  attacks  of  her  opponents,  and  Heaven  and  hell  in 
lively  colors,  and  thus  excite  and  confuse  them. 

Sometimes  misfortunes  drive  these  religious  imbeciles  into  the 
arms  of  religion  and  remove  them  from  the  world  of  material 
interests. 

In  many  patients  who  become  the  victims  of  religious  paranoia 
at  the  time  of  puberty  there  are  states  of  mental  excitement  which 


404  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

express  themselves  in  religious  enthusiasm,  or  in  the  impulse  to  be- 
come priests,  to  go  into  a  convent,  to  make  pilgrimages,  etc.;  and 
sometimes  in  connection  with  these  there  are  visions  of  heavenly 
persons. 

The  outbreak  of  the  actual  disease  is  brought  about  by  physical 
enfeebling  causes,  whether  these  be  acute  diseases  or  sexual  excesses, 
or  the  inanition  resulting  from  penances  and  fasting.  Exciting 
psychic  causes  are  disappointment  in  love,  grave  misfortunes,  or  en- 
tbusiastic  sermons  and  ideas  of  a  mission  which  call  up  scruples  of 
conscience  or  render  doubtful  the  possible  attainment  of  eternal 
happiness. 

The  stage  of  incubation  of  this  disease  may  last  through  months 
or  years.  In  females  there  are  frequently  observed  chlorotic  symp- 
toms, hysteria,  disturbances  of  menstruation,  as  signs  of  physical 
sulTering;  in  males,  hypochondriac  tendencies.  In  both  sexes  anom- 
alies of  the  sexual  instinct  are  very  frequent,  in  that  this  is  abnor- 
nuilly  intense,  manifested  too  early,  and  leads  to  onanism. 

The  candidates  for  religious  paranoia  at  this  stage  have  no 
desire  for  work  and  are  lost  in  thought.  They  prefer  to  read  the 
holy  writings  and  religious  tracts,  give  themselves  up  to  pilgrimages 
and  missions,  and  neglect  their  social  duties.  With  the  occasional 
intensified  religious  exaltation  (in  women  always  at  the  time  of  the 
menses),  there  are  invariably  signs  of  eroticism,  which  are  shown 
more  or  less  clearly  in  onanism  and  in  sexual  promiscuit}^  or  in  a  kind 
of  spiritual  enthusiasm  for  certain  priests,  saints,  etc. 

The  beginning  of  the  active  stage  of  the  disease  is  characterized 
by  the  occurrence  of  hallucinations  as  a  part  of  the  manifestations 
of  states  of  mental  excitement,,  which  may  be  intensified  to  ecstasy 
and  accompanied  by  sleeplessness. 

Sublime  feelings  of  the  sinful  body  l)cing  permeated  by  the 
divine  breath  come  into  consciousness,  and  in  these  states  remove 
the  individual  from  earthly  interest  and  cares.  A  feeling  of  beati- 
tude invades  the  patient,  as  if  the  Holy  Ghost  had  come  over  them; 
in  women  at  the  same  time  there  is  very  fre(|uently  sexual  excite- 
ment even  with  feelings  of  coitus,  which  find  their  expression  later 
in  delusions  of  immaculate  conception.  In  these  states  of  ecstasy 
cataleptiform  symptoms  may  occur. 

At  first  the  hallucinations  are  merely  visions — the  patients  see 
heaven  open,  the  A^irgin  smiles  kindly  at  them,  the  wonders  of  the 
Apocalypse  are  shown  to  them,  and  they  sec  tlic  liravcnly  light  aroiind- 
them,  etc.  Later,  with  the  return  of  these  liallncinatory  ecstatic 
states  of  happiness,  they  also  hear  voices:  "This  is  my  beloved  Son,"' 


PSYCHIC  DEGENERATIONS.  40 o 

projDliecieS;,  promises,  comrnandnicnts,  and  missions  for  the  vocation 
of  a  prophet,  etc. 

Such  hallucinations  continue  into  the  later  stages  of  the  disease. 
Asceticism  and  onanism  are  influences  which  cause  them  to  return 
at  any  time  with  special  intensity.  The  product  of  this  patliologic 
process  is  delusions — in  males,  as  a  nucleus  of  the  whole  delusional 
system,  that  of  being  a  saviour;  in  females,  that  of  being  the  Mother 
of  Christ.  They  are  developed  with  surprising  rapidity,  in  that  the 
person  usually  originally  perverse  quickly  loses  his  remaining  reason. 
The  slight  opposition  still  encountered  is  felt  to  be  the  opposition  of 
the  devil,  and  is  soon  victoriously  overcome. 

A  further  iinportant  source  of  delusions,  aside  from  the  primor- 
dial delusions  and  errors  of  the  senses,  is  the  paralogia  of  these 
patients,  as  a  result  of  which  they  interpret  passages  from  Holy  Writ- 
ings in  a  perverse  way  and  bring  them  into  relation  with  their  own 
person. 

As  long  as  the  delusion  is  fresh  and  accompanied  by  affects  and 
sustained  by  hallucination,  such  patients  are  inclined  to  act  in  ac- 
cordance Avith  it,  whether  that  be  in  the  harmless  role  of  a  preacher 
in  the  desert  or  as  reformers  and  saviours  of  the  world;  and  in  this 
way  they  render  themselves  merely  ridiculous  and  impossible  in  so- 
ciety; or  they  may  assume  the  dangerous  role  of  a  champion  of  the 
divine  faith,  and  not  hesitate  to  oppose  the  enemies  of  God.  Certain 
nor]nal  fanatics  of  past  time  went  forth  before  the  unbelievers  with 
tire  and  sword.  Just  as  in  depressive  persecutory  paranoia,  in  ex- 
pansive religious  paranoia  in  general  two  stages  of  the  disease  are  to 
be  distinguished:  one  of  passivity,  in  which  the  patient  remains  sim- 
ply an  observer,  and  receptive  in  his  spontaneous  sublime  feelings  and 
hallucinations;  and  another  stage  of  activity,  in  which  the  completed 
delusion  seeks  to  become  actual,  and  thus  the  individual  comes  into 
conflict  with  the  world.  In  the  course  of  the  disease  of  these  Avorld- 
reformers,  messiahs,  and  virgins,  along  with  the  periods  of  inspiration 
or  ecstasy,  it  is  remarkable  to  note  paroxysms  of  profound  despair 
and  depression  of  feeling  of  self,  periods  of  doubt,  of  worthiness  in 
the  holy  calling,  feelings  of  sinfulness,  of  need,  of  purification  and 
penitence,  in  which  the  patients  refuse  food,  are  mute,  and  give 
themselves  up  to  the  most  intense  asceticism,  which  may  even  end 
in  self -mutilation ;  and  as  a  result  of  precordial  anxiety  and  diabolic 
visions  they  even  think  themselves  to  be  threatened  by  the  devil. 
As  a  rule,  these  demoniacal  attacks  quickly  pass,  and  continued  ascet- 
icism and  religious  concentration  quickly  cause  a  return  of  the  heav- 
enly visions. 


400  SPECIAL  PATHOLOGY  AND  TIIEKAPY  OF  INSANITY. 

The  furtlici'  course  of  the  inahidy  is  unii'orm  in  all  cases.  Since 
sucli  individuals  cannot  occuj:»}'  a  jihice  in  societ}^,  there  is  frequent 
occasion  to  study  the  termination  of  the  disease  in  asyluuis. 

]n  favorahlc  cases  isolation  in  an  asylum^,  where  the  reuioval  ol' 
all  oltjects  of  rclig-ious  observance  antl  occasion  for  religious  prac- 
tices must  he  .carried  out,  the  i-cligious  e.\altatii)ii  diminishes,  the 
l)atient  Ix'comes  more  reasoiuible,  antl  Avitli  the  cessation  of  the  hal- 
lucinations the  disturbance  sinks  to  its  former  level  of  religious  ec- 
centricity. The  disposition  to  rcmKU'srcncc  of  the  disturl)ancc,  as 
a  result  of  psychic  and  somatic  exciting  causes,  continues.  Jf  siicli 
l)atients  enter  an  asylum,  and  their  delusion  does  not  disappcai'.  ilicii 
the  institution  seems  to  them  cither  a  prison  or  a  place  of  inartyr- 
dom,  trial,  etc.,  and  they  take  pleasure  in  the  role  of  a  noble,  lazy 
martyrdom,  and  comfort  in  their  glorious  ideas,  sustained  by  halluci- 
nations, of  the  future  assumption  of  their  divine  calling,  or  the  time 
that  has  not  yet  been  fulfilled. 

In  the  beginning,  such  23atients  now  and  then  cause  disturbance 
l)y  their  proselyting  and  outbreaks  of  fanaticism  toward  the  wicked 
world.  Later  they  become  quiet,  and  even  sometimes,  if  their  de- 
lusions become  sufficiently  faded,  industrious  patients. 

In  their  paroxysms  of  depression,  in  which  they  are  in  combat 
with  the  devil,  and  when  they  give  themselves  up  to  penance  and 
fasting,  refusal  of  food  is  quite  usual,  but  they  seldom  require  forced 
feeding. 

Such  patients  'are  always  dangerous  to  themselves,  because  of 
their  tendenc}'  to  undertake  self-mutilation  and  even  crucifixion  as  a 
result  of  their  own  impulse  or  of  divine  command.  Othci's  arc  dan- 
gerous because  of  acts  of  fanaticism  or  commands  from  God,  or  crazy 
interpretations  of  Bible  quotations. 

Eeligious  paranoia  terminates  in  states  of  mental  weakness,  in 
which  the  delusion  still  exists,  but  only  as  a  phrase,  and  is  no  longer 
excited  and  sustained  by  hallucinations  or  by  ecstatic  states  of 
feeling. 

Termination  in  complete  apathetic  dementia  does  not  occur  in 
this  variety  of  paranoia. 

Case  29. — Iicligious  paranoia. 

E.,  aged  42,  inarried,  peasant,  Avas  bronglit  to  the  asylum  June  ß,  1874, 
on  account  of  religious  insanity.  He  Avas  said  not  to  be  hereditarily  predis- 
posed, and  to  have  been  mentally  and  physically  healthy;  still  he  was  re- 
garded as  quarrelsome  and  given  to  disputes.  He  was  also  suspected  of  hav- 
ing committed  perjury. 


PSYCHIC  DEGENERATIONS.  407 

In  the  fall  of  1873  there  was  a  revival  in  the  village,  which  the  patient 
frequented  regularly.  He  made  a  general  confession,  and  it  is  said  that  a 
very  severe  penance  was  inflicted.  From  that  time  he  was  changed,  no  longer 
worked,  and  passed  his  days  at  church.  He  took  on  an  unctuous  manner  and 
declared  that  he  was  destined  for  something  higher.  He  allowed  his  hair  and 
beard  to  grow  because  his  body  was  holy  and  tliey  should  not  be  cut.  On  one 
occasion  when  he  was  praying  in  church,  artificial  flowers  fell  from  a  candle. 
He  stuck  these  in  his  hair  and  said  that  they  were  a  bridal  present  that  had 
fallen  to  him  from  llea.ven;  for  he  was  the  bridegroom  of  Uk^  Virgin  and  des- 
tined to  rule  the  world  in  the  future,  for  the  ancient  God  was  no  longer  of 
value.  His  wife  and  children  were  the  only  obstacles  which  prevented  him 
from  marrying  the  Virgin  at  once;  but  he  would  exterminate  these  useless 
people. 

On  May  10,  1874,  the  patient  became  still  more  evay.j.  lie  dressed  him- 
self only  in  his  best,  adorned  with  the  flowers  that  had  fallen  from  Heaven, 
and  walked  and  demeaned  himself  in  a  most  haughty  vi^ay,  saying  that  he 
would  do  only  that  which  was  commanded  to  him  from  on  high.  He  was  not 
to  work  any  more,  for  the  missionary  had  said  that  he  was  destined  for  higher 
things,  and  that  God  would  care  for  wife  and  children. 

In  the  asj'lum  the  patient  has  a  lordly  manner.  He  keeps  away  from 
the  other  patients,  and  is  occupied  with  a  feeling  of  his  high  mission,  con- 
cerning which,  however,  he  does  not  speak  much.  Often  he  is  found  within  the 
embrasure  of  a  Avindow  with  a  look  of  ecstasy  in  his  face.  The  patient  sleeps 
little  at  night  and  evidently  has  hallucinations. 

On  January  6,  1875,  the  patient  left  his  reserve.  He  declared  himself  to 
be  almighty  and  conscious  of  his  poAver  since  a  month.  Every  day  he  saw  the" 
Divine  Judge  and  the  Virgin.  She  is  kneeling  and  in  a  red  dress,  God  the 
Father  near  her  with  a  red  head-dress.  Heaven  is  blue,  beautiful,  and  filled 
Avith  altars.  It  Avas  true  that  up  to  that  time  he  had  not  spoken  Avith  the 
HeaA'ehly  Hosts,  but  the  missionary  had  told  him  Avhen  he  made  his  general 
confession  that  he  Avas  the  Son  of  God  and  would  become  greater  than  God. 
This  Avas  still  a  secret.  After  this  he  had  SAA^eat  blood.  The  clnu'ch  in  E.  Avas 
reserved  for  him.  As  yet  he  could  perform  no  miracles;  for  the  ancient  God 
still  reigned.  Christ  was  St.  John,  and  he  the  real  son  of  Mary  and  the 
A'eritable  son  of  God.  He  Avould  never  die,  but  go  directly  to  HeaA^en,  Avhere 
he  Avould  take  God's  place  and  sit  at  the  right  hand  of  God. 

Near  tlie  picture  of  the  Virgin,  a  cane  and  a  ring  had  fallen  from  HeaA^en. 
In  the  church,  floAvers  had  fallen.  The  cane  Avas  the  rod  of  punishment  AAhicli 
he  must  use.  The  flowers  Avere  signs  of  the  ancient  God  noAV  deposed,  in 
AA'hose  place  and  next  to  Avhom  he  Avould  be  installed.  He  took  an  old  um- 
brella in  all  earnestness  as  haA'ing  been  throAvn  from  Heaven  and  really  com- 
ing from  God.  He  declared  Mary  to  be  his  earthly,  Avife,  and  that  he  must 
remain  on  earth  until  his  earthly  wife  should  die,  Avith  Avhom,  hoAvever,  he 
must  no  longer  associate. 

His  acts  and  attitude  are  inspired  from  above.  His  duty  is  to  visit  the 
cliurch.  He  has  no  other  Avork  to  do;  for  he  is  almighty.  He  takes  the 
asylum  to  be  the  house  of  God. 

The  patient  takes  pleasure  in  his  noble,  pious  position,  and  politely  re- 
fuses all  efi'orts  to  induce  him  to  occupy  himself  usefully.  As  a  harmless 
patient,  he  Avas  giA'en  OA'er  to  be  cared  for  as  a  chronic  incurable.     Tavo  years 


408  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

later  I  had  occasion  to  see  the  patient  temporarily.     He  was  lying  quietly  in 
bed,  patiently  awaiting  the  time  when  he  should  take  up  his  divine  mission. 

There  was  a  very  interesting  complete  anesthesia  and  analgesia  of  the 
body,  with  the  exception  of  the  mucous  membrane  of  the  tongue  and  a  point 
over  the  parietal  region.  Patient  did  not  feel  the  Strongest  electric  stimuli. 
With  his  eyes  closed,  he  was  not  conscious  of  passive  position  giA'en  to  his  ex- 
tremities, lliough  he  could  carry  out  any  movements  at  command  promptly 
and  without  any  ataxia. 

i>'.  Erotic  Paranoia  (Erobomania). 

Still  another  variety  of  paranoia,  less  studied  and  al^o  relatively 
infrequent  as  compared  with  other  varieties,  is  that  known  as  erotic. 

In  all  cases  of  my  observation  the  individuals  have  been  peculiar, 
and  their  abnormal  psychic  characteristics  could  be  referred  to  hered- 
itary influences  or  to  infantile  diseases  of  the  brain. 

The  nucleus  of  the  whole  malady  is  the  delusion  of  being  dis- 
tinguished and  loved  by  a  person  of  the  opposite  sex  who  regularly 
belongs  to  one  of  the  higher  classes  of  society.  The  love  for  this 
j)erson  is,  as  should  be  emphasized,  romantic,  enthusiastic,  but  ab- 
solutely platonic.  These  patients  in  this  respect  call  to  mind  the 
knights  and  minstrels  of  ancient  times,  whom  Cervantes  has  so  well 
satirized  in  his  ''  Don  Quixote." 

The}"  early  show  a  shy  and  awkward  manner  in  society,  which  is 
especially  noticeable  in  intercourse  with  persons  of  the  opposite  sex. 
Lively  expressions  of  sexual  instinct  that  finds  relief  in  sensual 
satisfaction  is  sought  in  vain  in  these  patients.  In  the  male  patients 
of  my  observation,  who  constitute  the  majority,  there  were  indica- 
tions of  absence  of  sexual  instinct,  or  perversity  which  led  to  onanism. 

The  abnormal  character  early  shoAvs  itself  in  a  soft,  sentimental 
habit  of  feeling.  Early,  at  least  at  the  time  of  pubcrt}^  traces  of  the 
later  primordial  delusion  appear,  in  that  such  individuals  create  an 
ideal  for  which  the}^  become  enthusiastic,  or  they  fall  in  love  with  a 
lady  usually  older,  Avhom  they  have  never  seen  or  whom  they  have 
seen  but  once  (Sander).  With  this  there  is  a  dream}^,  languid  man- 
ner, with  painful  and  often  also  hypochondriac  thoughts.  In  dreams 
and  in  fancy  the  romance  is  further  elaborated;  reminiscences  out  of 
fairy-tales  and  dream-pictures  furnish  food.  One  day  they  see  iu 
some  jDcrson  of  high  society  of  the  opposite  sex  the  incarnation  of 
their  ideal. 

With  this  the  stage  of  incubation  of  the  actual  malady  begins. 
In  the  glances  and  manner  of  the  person  they  notice  that  the  latter  is 
not  indifferent  to  them.  With  surprising  rapidity  reason  is  over- 
come. The  most  harmless  events  become  to  them  signs  of  love  and 
invitations  to  approach.    Even  notices  in  the  newspapers  which  con- 


PSYCHIC  DEGENERATIONS.  409 

cern  others  come  from  tlie  person  in  question;  finally  hall iieinal ions 
arise.  They  come  into  hallucinatory  relation  with  the  object  oi;  their 
love.  At  the  same  time  there  are  illusions.  In  the  conversation  of 
others  they  hear  references  to  the  love-affair.  The  patient  feels 
happy  and  elevated  in  his  feeling  of  self.  Kot  infrequently  there  are 
other  primordial  delusions  of  grandeur,  especially  when  the  object 
of  adoration  belongs  to  a  high  rank  and  therefore  wishes  to  obliterate 
the  difference  of  social  standing. 

Finally  the  patient  compromises  himself  by  acting  in  accordance 
with  his  delusions,  and  then  becomes  ludicrous  and  impossible  in 
society.  The  necessary  commitment  to  an  institution  or  hindrance 
offered  to  the  expression  of  love  not  infrequently  gives  rise  to  the 
development  of  primordial  delusions  of  persecution,  which,  however, 
have  only  a  subsidiary  episodic  significance. 

The  malady  is  subject  also  to  exacerbations  and  remissions,  in 
that  the  hallucinations  cause  the  delusions  temporarily  to  become 
intensified;  or  they  disappear,  and  then  the  delusions  fade.  Inter- 
missions also  occur.    I  have  never  seen  a  case  recover. 

Case  30.- — Erotic  paranoia  (male). 

S.,  aged  54,  single,  coachman,  was  admitted  to  the  clinic  February  2,  1878. 
Tlip  history  is  limited  to  statements  made  by  the  patient,  who  by  his  com- 
panions was  regarded  of  limited  mental  endowment,  peculiar,  and  given  to 
solitude;  Avlio  had  lived  alone  soberly,  and  never  troubled  himself  much  about 
women. 

The  patient  states  that  for  several  months  he  had  noticed  that  the  sister- 
in-law  of  the  baron  Avhere  he  was  employed  had  manifested  an  affection  for 
him.  By  friendly  majiner  and  inviting  glances  she  had  given  him  to  under- 
stand that  she  wished  to  marry  him.  At  night  he  heard  voices  which  told  him 
to  go  upstairs  to  the  baroness,  and  he  heard  the  baron  say,  "We  wish  to 
please  him  and  give  him  R.  as  a  wife."  Too,  the  baroness  expressed  her  acqui- 
escence if  he  should  continue  his  good  conduct.  The  servants  in  the  house 
also  spoke  of  this,  and  took  pleasiu'e  in  his  happiness;  only  the  cook,  Avho  had 
herself  cast  an  eye  at  him,  was  jealous  and  intrigued  against  him  by  talking 
to  the  baroness  about  him  and  putting  him  in  a  bad  light,  and  furnishing  him 
with  inferior  food. 

The  pleasant  voices  continued— among  other  things  he  heard  that  the 
baron  had  already  gone  to  the  emperor  for  pennission  of  marriage,  since  the 
lady  looked  upon  'him  so  kindly,  even  ran  after  him  into  town,  and  the  best 
society  Avas  clearly  acquiescing  in  their  union.  One  day  he  went  to  his  master 
and  demanded  the  hand  of  his  sister-in-law.  To  his  astonishment  and  pain  he 
was  repelled  and  sent  to  the  hospital. 

The  patient  Avas  of  middle  size,  strongly  built,  without  signs  of  degenera- 
tion, pulse  very  sIoav,  the  arteries  rigid  and  clearly  sclerotic.  There  were  no 
other  functional  disturbances  of  importance.  The  patient's  conduct  was  re- 
served and  shj;  he  Avas  often  simk  in  dreamy  thought  and  apparently  occu- 
pied with  hallucinations.     He  later  said  that  eA^ery  night  he  heard  the  baron 


410  SPECIAL  PATHOLOGY  AND  TllKKAPY  OF  INSANITY. 

talking  about  tlie  matter.  He  had  heard  liim  say  to  his  sister-in-law:  "Marry 
him,  use  him  as  long  as  you  want  him,  and  then  send  him  away."  He  also 
noticed  that  the  family  had  sent  some  one  to  watch  over  his  conduct. 

Since  the  patient  was  quiet  and  orderly  and  admitted  that  he  had  made 
a  mistake,  and  promised  not  to  trouble  the  baron  any  more,  he  was  discharged 
on  February  12,  187S.  \\'hen  on  the  same  day  he  wished  to  take  his  things 
away  from  the  baron's  iuune,  the  baroness  came  to  him  and  wished  to  give  him 
money  in  order  to  lielp  liim.  He  heard  her  say  this  to  the  servants.  A  trtci'i- 
tcte  was  prevented  by  the  baron.  After  this,  here  and  there  he  heard  the 
people  talking  about  the  story  of  his  marriage.  Two  young  gentlemen 
laughed  at  him  in  the  street  and  said:  "If  he  marries  her  he  will  be  obliged  to 
become  her  valet."  AA'hen  he  sought  for  another  place  no  one  would  take  him, 
and  he  heard  tlie  people  say:  "We  cannot  take  this  man  because  he  is  expect- 
iiiL;  Iti  lie  nianieil."  At  limes  lie  heard  Uiat  K.  olVered  hiin  1000  liorins. 
Thereafter  he  heard  the  baron  say  to  his  wife:  "We  should  have  one  of  his 
children  as  a  grandeliild;  he  is  such  a  fine  fellow  and  his  body  is  as  white  as 
snow." 

April  10th  the  people  in  the  house  said:  "The  baron  has  said  that  he 
wished  to  please  him;  if  he  returns  he  will  have  her  hand";  and  tlien:  "If  he 
does  not  accept  it,  I  shall  denounce  him  to  the  authorities." 

April  nth  the  patient  thought  that  he  had  seen  the  baroness  and  her 
sister  in  the  park.  Having  come  near  tlieir  home,  he  heard  several  coachmen 
saying  that  the  ladies  were  looking  for  him. 

In  order  not  to  injiu-e  the  ladies  and  the  baron,  he  again  went  to  the 
latter  and  declared  his  willingness  to  marry  the  baroness  K.  or,  if  it  was  pre- 
ferred, her  sister.  He  was  also  ready  to  accept  the  1000  florins  offered.  The 
baron  received  him  very  ungraciously  and  hastened  his  descent  down  the  steps. 
Deeply  hurt  and  quite  out  of  himself  for  pain,  the  patient  returned  home,  went 
to  bed,  and  burst  into  tears.  Then  the  police  came  and  took  him  back  to  the 
hospital. 

The  patient  entered  with  an  embarrassed  mien  and  asked  that  they 
should  allow  the  baroness  to  enter  when  she  should  come  to  make  inquiry 
about  his  health.  He  soon  learned  from  the  conversation  of  those  about  him 
that  she  had  already  been  there.  He  heard  her  also  reproach  her  brother-in- 
law  tliat  he  had  shown  him  the  door. 

The  patient  was  quiet,  outwardly  orderly,  but  much  occupied  with  voices, 
especially  at  night,  when  he  often  got  up,  kneeled,  and  prayed.  The  patient 
regarded  his  detention  as  a  trick  of  the  baron,  who  had  sworn  to  avenge  him- 
self, and  had  threatened  to  persecute  him  even  unto  death  if  he  did  not  make 
an  honorable  apology.  He  heard  the  baron  say  by  the  mediinn  of  the  voices: 
"I  shall  turn  everything  up  and  continue  rmtil  I  have  found  something  against 
him,  if  it  cost  me  my  whole  fortune."  By  the  "rain  conductor"  the  patient 
learned  everything  that  took  place  and  was  planned  without.  Investigations 
were  made  concerning  him.  The  origin  of  the  baron's  hostility  was  that  he, 
as  candidate  for  the  hand  of  his  sister-in-law,  was  much  smarter  than  the 
baron  and  understood  agriculture  as  only  a  few  did,  while  the  baron  Avas  an 
inferior  agrieultiu-ist.  On  the  other  hand,  he  received  pleasant  news  by  the 
"conductor"  again;  among  other  things,  that  he  had  been  designated  as  gen- 
eral of  the  national  guard,  that  the  emperor  had  given  him  a  title,  and  had 
consented  to  his  marriage.     The  baroness  also  let  him  know  that  she  was  fond 


rSYCTTTC  DEGENERATIONS.  411 

of  him  and  wished  tliui  Ik'  would  remain  Iriie  (o  hci-.  Miuilly  lie  liem-d  a  siiin 
of  money  spoken  of  as  promised  to  him  if  lie  would  f^ive  up  the  mari-ia^e.  On 
June  3,  1878,  the  patient  was  sent  to  the  insane  asylum.  At  first  he  was  quite 
orderly  and  was  employed  to  take  care  of  the  horses.  Repeatedly  during  this 
period,  by  means  of  the  "condnetor,"  he  learned  that  the  baroness  had  come 
to  see  him.  He  saw  her  re])eate(lly  in  the  ehicken-yard  where  he  fed  the 
chiekens  (illusion).  After  a  short  time  the  patient  notieed  that  he  Ava«  the 
objeet  of  attention  of  the  ladies  in  tiie  house.  Now  the  intrigue  by  these 
ladies  began.  ,  They  maltreated  him  in  riddles,  interfered  with  his  love-aflair 
with  the  baroness,  and  made  proposals  of  love  to  him.  He  was  told  now  that 
he  had  three  brides.  From  day  to  day  the  patient  became  more  confused  by 
numerous  hallucinations.  There  was  pleasant  news  of  marriage,  as  Avell  as  of 
poison  and  impleasant  threats  of  death,  lie  had  pain  in  his  liaek  and  lower 
extremities  of  the  most  terribl(>  kind,  and  heard  the  hidics  in  tlie  house  say: 
"We  shall  torture  him  until  he  takes  one  of  us."  One  night  a  crown  was  put 
on  his  head.  It  was  hot  and  his  head  burned  three  days  thereafter.  With 
this  he  felt  his  brain  turned  around. 

The  wife  of  the  coachman  was  also  in  the  plot.  One  evening  she  came 
with  her  husband,  who  was  dressed  like  the  devil,  to  visit  him  in  the  ward. 
He  felt  the  Avarm  hand  of  the  coachman's  wife.  When  he  cried  out  and 
crossed  himself,  everything  disappeared.  In  the  course  of  the  summer  the 
wife  of  one  of  the  physicians  insulted  him  with  coarse  reproaches  from  the 
window — that  he  Avas  a  dirty  felloAV  who  iised  coavs,  etc.  There  were  direct 
symptoms  of  sexual  excitement:  the  women  in  the  house  urged  him  on  until 
he  had  an  erection  and  Nature  came,  and  he  felt  a  pain  in  his  back  (onanism). 
The  women  oppressed  him  so  that  he  could  scarcely  breathe.  His  brain  also 
was  pressed  together.  He  heard  one  of  the  Avomen  often  barking  like  a  dog. 
One  night  she  came  to  him  through  the  ventilator.  He  did  not  see  her,  but 
he  felt  her  lean  body.  She  asked  him  for  a  kiss.  When  he  chased  her  away 
there  was  a  terrible  noise,  which  ceased  immediately  Avhen  he  prayed.  It  Avas 
clearly  a  visit  of  the  devil  whom  he  later  saw  once  in  the  flesh.  The  next  day 
he  learned  by  the  "conductor"  that  the  woman  was  dead  and  that  she  thanked 
him  for  having  delivered  her.  From  this  time  he  heard  only  the  A^oices  of  the 
two  other  brides.  The  others,  hoAvever,  never  left  him  any  rest.  They  con- 
stantly asked  that  he  marry  them. 

August  25,  1879,  the  patient  Avas  transferred  to  an  institution  for 
incurables. 

Case  31. — Erotic  paranoia  (female). 

L.,  aged  45,  AvidoAV  of  an  official,  comes  of  a  religious,  eccentric,  psycho- 
pathic father.  Puberty  occurred  at  the  age  of  12  Avithout  trouble,  and  the 
menses  recurred  regularly  thereafter.  The  patient  has  neA'^er  had  children. 
At  the  age  of  16  she  Avas  married,  but  her  marriage  Avas  not  happy.  The 
patient  states  that,  on  account  of  a  quarrel,  during  four  years  she  did  not 
speak  to  her  husband.  She  became  a  AvidoAv  after  seA'cn  years.  After  this 
she  lived  in  Avell-ordered,  but  moderate,  circumstances,  adopted  tAvo  children: 
a  girl  Avhom  she  called  her  "Little  Brilliant,"  and  a  boy,  Avhom  she  called 
"Golden  Cousin." 

The  patient  is  an  original,  eccentric,  exalted  person.  She  has  always  had 
great  inclination  to  poetry,  music,  and  the  theater,  but  she  did  not  choose  the 


412  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

occupation  of  an  actress  because  she  Avas  not  noble  enough.  She  characterizes 
lierself  as  a  very  sympathetic,  enthusiastic  woman,  Avho  is  very  sensitive  to 
everything  noble  and  good.  She  had  always  been  healthy  with  the  exception 
of  some  attacks  (cerebral  congestion,  fainting),  on  account  of  which  she  had 
been  bled.  There  is  little  else  to  be  learned  about  her.  Traces  of  hysteria  are 
not  discoverable,  and  the  patient  seems  to  have  led  an  honorable  and  retired 
life.  Five  years  ago  the  patient  made  the  acquaintance  in  the  circle  of  her 
friends  of  an  ofllccr  of  high  grade.  He  made  a  deep  impression  on  her.  Be- 
cause it  was  said  that  he  once  called  her  a  good  gentle  woman  and  later  asked 
news  of  her  and  sent  greetings  to  her,  she  also  was  not  indillerent  to  him. 
She  approached  him,  sent  him  photographs,  sent  him  her  address,  presents, 
and  wrote  him  letters.  Everything  came  back  unopened,  and  in  the  street 
the  gentleman  avoided  her.  She  was  very  much  hurt  by  this,  but  in  spite  of 
it  she  could  not  conquer  her  burning  love  for  her  object  of  devotion.  One  day 
she  noticed  that,  while  he  openly  disavowed  her,  there  were  personals  in  the 
newspapers  directed  to  her  address.  She  recognized  that  they  were  from  him 
by  the  style  and  by  peculiarities,— for  example,  the  initials  of  both  tlicir 
names;    and  there  was  no  longer  any  doubt  on  the  subject. 

Thus  one  day  she  read:  "If  you  can  only  think  of  a  bleeding  heart  that 
can  be  cured  only  by  your  treatment."  There  were  renewed  attempts  to  ap- 
]n-oach  him,  letters,  etc.,  the  result  of  which  was  the  personal:  "Had  you  left 
me  in  peace — ^no  answer  is  still  an  answer";  after  that  she  inserted:  "He 
could  grow  stronger  in  my  heart."  Then  thereafter  there  was  a  coarse  an- 
swer, and  finally  a  reconciliation  with  "Forget-me-not."  In  answer  to  a  new 
personal,  "Preserve  the  object  of  my  devotion,  my  light  of  Heaven,"  she  read: 
"I  am  here,  I  am  in  Gratz."  Then  the  patient  pursued  the  object  of  her  devo- 
tion and  finally  met  him  while  taking  a  Avalk.  Instead  of  a  friendly  meeting 
she  heard  the  gentleman  say  "You  wretch."  Then  she  fainted.  Nevertheless, 
in  spite  of  tliis,  she  found  afterward  friendly  communications  in  the  news- 
papers. In  spite  of  her  pain  she  was  forced  to  answer  them,  she  loved  him  so 
much.  She  answered  quite  as  kindly  in  letters,  and  wrote,  among  other  things: 
"My  little  room  is  small  and  without  adornment,  but  love  of  my  object  of  de- 
votion fills  it."  To  her  annoya.nce,  however,  he  always  passed  by  her  house 
(illusion:  i.e.,  mistaking  of  persons),  but  he  never  came  in.  A  trip  on  a  mat- 
ter of  business  took  her  away  for  a  time.  After  her  return  the  gentleman  had 
disappeared.  She  found  out  his  whoreaboiits  and  went  after  him.  New  luimili- 
ations  ajid  new  refusal,  notwithstanding  the  fact  that  she  had  given  him  all  her 
soul.  In  great  distress  she  set  out  for  Budapest.  Scarcely  had  she  arrived 
when  she  found  in  the  newspaper  this  advertisement:  "Eeady  to  make  all 
sacrifices  in  order  to  have  a  reconciliation."  She  returns  and  sends  a  carnation 
with  these  words:  "May  the  noble  perfume  of  the  carnation  fill  the  abyss 
which  separates  us."  Eenewed  humiliation  and  attack  of  fainting.  De- 
nounced by  this  gentleman,  she  had  to  justify  herself  before  the  police.  She 
was  dismissed  after  being  lectured.  She  resolved  to  avoid  the  unfaithful  one. 
Soon  after  she  again  read  in  the  newspaper:  "I  am  waiting  for  you."  It  is 
said  that  the  patient  in  a  dccollclö  gown  again  pursued  the  gentleman,  and 
that  she  even  wished  to  send  him  obscene  photographs.  This  was  the  cause  of 
her  being  sent  to  the  hospital  that  her  mental  condition  might  be  examined. 
There  also  the  advertisements  in  newspapers  continued:  "PTappv  future;  all  is 
already  arranged."    The  patient  resigns  herself  to  the  inevitable.     She  cannot 


PSYCHIC  DEGENERATIONS.  413 

understand  the  double  nature  of  the  man,  nor  her  deception.  In  spite  of  all 
that  has  happened,  she  loves  her  object  of  devotion  alwa/ys  Avith  eiitliusiasin. 
She  is  incapable  of  all  judgment. 

Hallucinations  are  absolutely  wanting  in  the  disease-picture,  which  is 
made  up  merely  of  fancies  and  illogical  interpi'etation  of  advertisements  which 
are  brought  into  relation  with  lier  own  personality,  and  all  takes  place  purely 
in  the  intellectual  domain.  Physical  examination  oirers  no  points  for  an 
luideistanding  of  the  case. 

The  patient  is  well  preserved;  expression,  glance,  and  attitude  all  bear 
the  impress   of  insanity. 


CHAPTER  IV. 
Periodic  Insanity. 


The  fact  that  insanity  recurs  periodically  in  attacks  is  one  that 
was  early  recognized.  It  points  to  periodic  recurrence  of  similar 
changes  in  the  psychic  organ  which  shows  a  special  predisposition  to 
their  recurrence. 

It  is  probable  that  this  disposition  should  be  considered  as  a  lasting 
abnormal  change  in  the  psychic  organ  analogous  to  that  which  is  called  the 
epileptic  change  of  the  brain  and  which  is  responsible  for  the  occurrence  of  epi- 
leptic attacks.  Among  other  things  this  idea  is  favored  by  the  circumstance 
that,  during  the  periods  between  the  paroxysm,  the  central  organ  does  not 
perform  its  functions  normally  and  is  thus  continually  affected.  Only  in  this 
way  is  it  possible  to  explain  that  intangible  or  extremely  slight  external 
causes,  and,  as  a  rule,  even  inner  functional  processes,  such  as  the  physiologic 
phases  of  life  (puberty,  menstruation,  climacteric),  suffice  to  give  origin  to 
periodic  insanity  or  to  excite  attacks  of  it.  Concerning  the  anatomic  nature 
of  the  cerebral  changes  which  lie  at  the  basis  of  periodic  insanity,  we  know 
quite  as  little  of  a  positive  nature  as  Ave  do  in  the  case  of  epilepsy.  From  the 
purely  functional  standpoint  it  may  be  presumed  that  there  is  a  lasting  state 
of  labile  equilibrium  which  may  temporarily  be  intensified  with  an  increased 
excitability,  of  the  central  organ,  and,  as  a  result  of  this,  intracerebral  or 
peripheral  irritative  processes  occurring  periodically,  or  their  summation,  may 
induce  the  attack. 

Too,  concerning  the  cerebral  changes  Which  lie  at  the  basis  of  the  attack 
itself,  we  possess  only  theoretic  assumptions. 

After  Neftel,  in  a  case  observed  by  him  of  recurring  melancholia,  had 
regarded  a  state  of  vasomotor  sj^asm  in  certain  areas  of  the  cortex  and  the 
resulting  anemia  as  the  cause  of  the  melancholia,  and  had  upon  this  theory 
applied  galvanization  of  the  cervical  sympathetic  in  the  case  with  success, 
Meynert  emphasized  the  possibility  that  in  this  condition  there  was  an  altered 
state  of  innervation  of  the  vasomotor  nerves.  This  author  assumes  that  in 
the  circular  form  of  periodic  insanity,  in  the  melancholic  phase  of  the  disease- 
picture,  there  is  cerebral  anemia  due  to  vasomotor  spasm;  and  in  the  maniacal 
phase,  cerebral  hyperemia  due  to  disappearance  of  the  spasm  with  consequent 
overfilling  of  the  blood-vessels;    and  that  circular  insanity  is  thus  to  be  re- 


41-i  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

gartlcd  now  as  a  spastic,  now  as  a  iniralylio.  ili>lml)aiu'c  of  iimoivalion,  form- 
ing part  of  a  vasomotor  cerebral  neurosis. 

Tliis  theory  requires  eonliruiation  by  suniclont  sphygmograpliic  studies. 
Experience  thus  far  sliows  the  intense  eoneomitant  implication  of  the  vaso- 
motor nerves  in  tliis  disease;  but  the  qualities  of  spasm  and  paralysis,  as 
sliown  in  the  pulse,  do  not  completely  corri'spuiid  in  liiiic  with  I  he  uu'lancliolir 
and  maniacal  phases;  so  it  seems  justiliablo  to  assume  that  the  important 
vasomotor  anomalies  do  not  occasion  the  psychic  disturbances,  but  that  they 
are  manifestations  co-ordinated  witli  them.  Likewise,  the  lindiugs  of  Meyer, 
contradicted  by  other  observeis,  idiucrning  the  peculiar  Nariations  of  body- 
weiglit  in  circular  insanity,  have  quite  as  little  significaiuc  in  favor  of  regard- 
ing the  disease-process  as  a  trophoneurosis  of  the  brain. 

Too,  concerning  the  stimuli  which  cause  the  paroxysms  or  phases  of 
periodic  insanity  we  know  scarcely  anything  positive,  at  least  not  in  the 
idiopathic  cases.  The  inqjortant  point  in  ctinlogy  must  be  regarded  as  tlie 
abnormally  organized  or  tainted  brain  of  the  patient,  whose  threshold  of  ex- 
citability lies  so  deep  that  internal  or  external  stimuli,  Avhich  are  without 
efl'ect  upon  the  normal  brain,  here,  like  those  affecting  the  brain  of  epileptics, 
are  sufHcient  to  bring  on  the  attacks. 

In  former  times,  and,  indeed,  not  to  go  back  so  far  as  Paracelsus,  but 
even  quite  in  our  own  daj',  the  nature  of  these  stimuli  has  been  regarded  as 
dependent  upon  atmospheric  (Reil,  Spurzhcim,  Call,  Forster,  Guislain)  and 
especially  upon  sidereal  influences  (the  moon— Friedreich,  Carus,  Koster).  In 
I  lie  ra>es  due  to  peripheral  irritation  (sympathetic)  it  is  most  frequently 
irritative  processes  affecting  the  uterine  nerves  (menstruation,  puberty)  which 
excite  the  attack.  Psychiatry  is  better  informed  concerning  the  etiology, 
course,  and  symptomatology  of  >  these  periodic  psychoses. 

Their  clinico-prognostic  significance  as  a  degenerative  manifestation 
Morel  fiist  clearly  recognized  and  appreciated. 

The  great  majority  of  these  patients  are  tainted,  and,  for  the  most  part, 
hereditarily.  It  is  rare  not  to  find  a  direct  or  family  predisposition;  and,  if 
the  taint  be  an  acquired  one,  it  is  due  to  fetal  or  infantile  diseases  of  the 
brain  or  abnormalities  of  the  ci-anium  (microcephaly).  Still  less  frequently 
the  cerebral  change  is  due  to  trauma  or  alcoholic  excesses. 

The  following  characteristics,  which  occur  in  all  forms  of  peri- 
odic insanity  and  Avhich  differentiate  them  from  non-periodic  forms, 
may  be  enumerated : — 

1.  The  typic  correspondence  with  reference  to  the  course  and 
symptoms  of  the  attacks.  In  his  excellent  monog-raph  Kirn  has 
lately  placed  in  the  diagnostic  foreground  this  fact,  wliicli  had  already 
heen  discovered  by  Falret  ("Maladies  Mentales/'  pages  458-462). 
This  stereotyped  correspondence  of  one  attack  Avith  another  holds 
good  even  for  the  prodromes,  the  content,  and  the  periodic  course  of 
the  symptoms  in  detail. 

This  correspondence,  however,  does  not  hold  good  for  the  whole  duration 
of  the  malady,  which  is  usually  lifelong,  nor  throughout  the  single  attack. 


PSYCHIC  DEGENERATIONS.  415 

In  the  first  place,  it  is  to  be  noted  that  the  periodic  psychosis  sometimes 
develops  out  of  repeated  relapses  of  insanity,  which  in  tlie  bcfjinning  does  not 
correspond  with  the  later  and  periodic  attacks  which  constitute  the  congruent 
psychosis;  and  that  during  its  years  of  existence,  probably  as  a  result  of  the 
inllucnce  of  secondary  cerebral  cliangcs,  it  may  change  its  picture;  for  ex- 
ample, become  more  severe  with  more  marked  indications  of  psychic  weakness. 

The  stereotyped  correspondence  between  the  attacks  therefore  holds  good 
only  for  a  comparatively  long  period  of  the  whole  duration  of  the  disease. 

Too,  the  duration  of  the  attack  varies  essentially,  notwithstanding  its 
congruence  in  other  respects,  in  that,  as  a  result  of  external  or  internal  con- 
ditions, it  may  be  abortive  or  protracted;  with  the  continuance  of  the  disease, 
the  attack  usually  becomes  juore  prolonged,  since  the  longer  the  return  of  an 
attack  is  put  olf,  the  longer  and  more  intense  is  its  actual  course. 

2.  The  Avhole  personality  is,  during  the  paroxysms,  mimically 
and  psychically  entirely  different  from  the  personality  during  the 
interval:   there  are  two  quite  different  personalities. 

3.  During  the  intervals  there  are  more  or  less  clear  manifesta- 
tions of  a  lasting  disease  of  the  central  nervous  system,  so  that  the 
single  attacks,  like  those  of  intermittent  fever  or  epilepsy,  are  only 
more  marked  symptoms  of  a  lasting  disease. 

The  symptoms  in  tlie  intervals  are  varied  and  individually  very  different. 
Often  they  are  signs  of  functional  degeneration,  and  appear  in  the  form  of  a 
neuropathic  constitution,  or  are  definable  as  accompanying  symptoms  of  a 
neurosis  which  is  the  expression  of  the  constitutional  taint  (hysteria,  neuras- 
thenia, epilepsy) ;  or  they  are  the  symptoms  referable  to  the  cerebral  changes 
due  to  the  repeated  attacks  (irritability,  psychic  weakness,  especially  in  the 
intellectual  domain — emotional  apathy) ;  or  they  are  the  symptoms  left  after 
an  attack  (mental  exhaustion),  precursors  of  a  threatening  attack,  or  symp- 
toms of  an  abortive  attack. 

4.  The  periodic  psychoses  occur  with  great  regularity  as  to 
time,  and  very  often  under  very  similar  external  and  internal  condi- 
tions. The  duration  of  the  interval  may  be  weeks,  months,  or  even 
years. 

The  value  of  this  law  is  only  in  a  measure  brought  in  doubt  by 
changing  external  conditions,  which  either  tend  to  hasten  the  occur- 
rence of  attacks  or  to  delay  their  outbreak. 

5.  The  disease-picture  is  principally  made  up  of  affective  anom- 
alies with  formal  disturbances  of  the  intellect  and  the  consequent 
abnormal  acts,  while  there  is  slight  or  even  no  disturbance  in  the 
content  of  thought  (delusions)  with  few  or  no  errors  of  the  senses. 
Where  there  are  delusions  in  cases  of  the  latter  kind  the  disease- 
j)icture  has  frequently  a  reasoning  coloring,  or  presents  features  like 
moral  or  impulsive  insanity. 


416  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

6.  The  average  duration  of  the  attacks  is,  in  general,  short  as 
compared  with  cases  in  which  the  symptoms  have  not  a  periodic  sig- 
niiieance. 

7,  The  paroxysms  of  periodic  insanity  have  a  short  prodromal 
stage,  quickly  reach  the  acme  of  the  disease,  remain  with  relatively 
slight  variations  of  intensity  at  this  height,  and  disappear  rapidly, 
often  even  quite  suddenly. 

These  general  points  are  to  be  considered  in  diagnosis. 

Since  the  diagnosis  rests  essentially  upon  the  comparison  of  sev- 
eral attacks  and  upon  observation  of  the  intervals  between  them, 
not  a  single  attack,  but  only  the  study  of  a  considerable  period  of  the 
whole  disease  can  give  it  certaint}'. 

The  prognosis  of  periodic  insanity  is,  as  must  be  gathered  from 
its  etiology,  in  general,  bad.  It  terminates  sometimes  in  recovery, 
and  this  is  most  likely  in  cases  that  are  sympathetically  caused  and 
amenable  to  treatment.  Eecovery  may  also  be  hoped  for  in  cases 
Avhere  the  attacks  present  more  the  character  of  delirium  than  of  a 
psychosis,  and  when  they  are  of  short  duration,  but  of  frequent  oc- 
currence. For  the  most  part  it  results  in  consecutive  states  of  men- 
tal weakness  with  gradual  disappearance  of  the  attacks  or  protraction 
of  them,  one  passing  into  another,  so  that  finally  there  arises  a  per- 
sistent insanity  upon  the  basis  of  mental  defect. 

Periodic  insanity  may  manifest  itself  in  the  form  of  a  psychosis 
or  in  delirium,  and,  in  the  former  case,  either  as  mania,  melancholia, 
or  hallucinatory  insanity,  and — in  the  manifestation  of  two  connected 
disease-pictures — as  circular  insanity. 

Genetically,  according  to  Kirn,  we  may  differentiate  two  forms — • 
idiopathic  {i.e.,  due  to  direct  central  prooesses)  and  sympathetic  {i.e., 
due  to  the  effect  of  peripheral  irritation  on  the  brain). 

I.  Pekiodic  Insan^itt  of  Idiopathic  Origin, 

Idiopathic  periodic  insanity  occurs  in  three  notable  clinical 
forms : — 

1.  Attacks  which  manifest  themselves  in  the  recognized  forms 
of  mania  or  melancholia,  or  in  a  combination  of  these  two,  in  which, 
for  the  most  part,  the  clinical  picture  of  the  lighter  form  of  maniacal 
exaltation  and  that  of  melancholia  without  delusion  are  the  rule,  and 
in  which  delusions  and  errors  of  the  senses  occur  only  episodically 
without  profonnd  disturbance  of  consciousness.  These  attacks,  in 
contrast  with  those  of  the  second  category,  as  was  emphasized  by 
Kirn,  are  characterized  by  the  fact  that  they  require  more  time  for 
theii'  termination — usually  months. 


PSYCI-IIC  DEGENERATIONS.  417 

2.  Attacks  which  clo  not  correspond  with  the  picture  of  an 
empiric  and  classic  psychosis,  but  with  the  features  of  delirium. 
These  are  accompanied  by  profound  disturbance  of  consciousness, 
and  have  a  peracute  or  acute  course,  and  terminate  in  a  few  days,  or 
at  most  in  a  few  weeks.  The  outbreak  and  the  disappearance  of  the 
attack  are  also  much  more  sudden  than  in  the  foregoing  group. 

3.  Attacks  manifested  in  the  form  of  abnormal  impulses. 

1.  Idiopathic  Periodic  Insanity  in  the  Form  of  a  Psychoneurosis. 

It  is  met,  at  least  in  institutions  for  the  insane,  most  frequently 
in  the  maniacal  form,  less  frequently  as  circular  or  melancholic,  and 
least  frequently  in  the  form  of  hallucinatory  insanity.  The  duration 
of  the  attacks  averages  usu.ally  some  months.  This  varies  according 
to  external  and  internal  conditions. 

There  are  also  abortive  attacks.  The  recurrence  of  attacks  takes 
place  after  months,  sometimes  only  after  years. 

The  disease-picture  is  usually  that  of  the  mild  form  of  simple 
affective  and  formal  disturbance  of  the  intellect,  in  many  cases  pre- 
senting a  reasoning  character. 

(a)  Periodic  Mania. 

In  opposition  to  the  ex]3erience  of  other  authors  (Sjoielmann, 
Schule,  Kirn),  according  to  which  a  melancholic  stage  precedes  the 
attack,  I  am  forced  to  insist  upon  the  primary  origin  of  the  attack 
of  periodic  maniacal  insanity,  at  least  while  the  cases  are  under  ob- 
servation in  the  asylum. 

There  may  be  cases  in  which  the  first  and  also  subsequent  attacks  of  the 
disease  show  such  a  melancholic  initial  stage;  certainly,  however,  this  disap- 
pears early  in  the  disease. 

Besides,  the  decision  of  this  question  depends  upon  what  one  regards  as  a 
melancholic  prodromal  stage. 

The  heavy  depressing  feeling  of  the  oncoming  attack  must  not  be  re- 
garded as  melancholia,  no  more  than  the  mental  indisposition  and  disturbance 
of  general  feeling  as  they  occur  in  the  prodromal  stage  of  infectious  diseases, 
even  when  irritability  and  apprehension  are  simultaneously  manifested  (Wit- 
kowsky). 

The  periodic  manias  that  have  come  under  my  observation  have  pre- 
sented a  prodromal  stage,  but  this  has  seemed  to  me  more  like  an  aura  than 
the  prodrome  of  a  psychosis.  The  premonitory  symptoms  belong,  in  part, 
to  the  vasomotor  sphere  (congestion,  palpitation,  vertigo) ;  in  part,  to  the 
sensory  system  (neuralgias,  myodynias,  paralgic  sensations,  headache);  in 
part,  to  the  mental  sphere  (intensification  of  emotional  irritability) ;  in  part, 
to  the  vagus  (gastric  disturbances) ;  or  they  express  themselves  in  sleepless- 
ness— all  of  which  might  just  as  well  be  the  forerunners  of  a  severe  infectious 
disease  as  of  a  psychosis. 


418  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  outbreak  of  the  mania  is  quite  sudden.  The  disease-picture 
is  that  of  maniacal  exaltation;  but,  owing  to  the  degenerative  foun- 
dation, it  presents,  for  the  most  part,  reasoning  features,  and  often 
the  character  of  moral  insanity  and  predominating  delirium  of  activ- 
ity, Avhich  then  frequently  has  an  impulsive  and  immoral  character. 

Among  tire  alfective  disturbances  the  intensely  increased  emo- 
tional irritability  takes  the  first  place,  and  as  a  result  thu  mania  is 
especially  colored  by  an  irritable  emotional  state. 

Owinof  to  the  want  of  disturbance  in  the  content  of  ideas,  and  the  reason- 
ing antl  often  immoral  and  inipulsive  features  of  all  the  manifestations,  the 
conduct  of  the  patient  may  give  the  impression  of  perversity  when  the  acts, 
and  not  the  wliole  personality  and  the  general  disea.se-picture  as  well  as  its 
intermitting  character,  are  not  taken  into  consideration.  This  is  especially 
true  of  cases,  which  are  not  infrequent,  in  which  the  impulsive  delirium  of 
action  conies  into  the  foreground  and  expresses  itself  in  an  impulse  to  sexual 
excesses,  to  steal,  to  drink,  to  burn,  to  wander,  etc.  Often  the  general  picture 
of  maniacal  insanity  is  only  clearly  recognizable  during  the  exacerbations  of 
the  disease. 

The  gay  mood  then  retreats  into  the  background  before  the  manifesta- 
tions of  irritability.  These  latter  show  themselves  in  sensitiveness  and 
inclination  to  intrigue  and  quarrels.  A  constant  feature  of  the  disease  in 
women  is  the  inclination  to  suspect  and  defame  women  sexually  as  a  result  of 
sexual  excitement.  The  exaltation  of  the  intellectual  activities  causes  such 
patients  to  be  especially  quick-witted,  and  to  be  masters  in  ridicule,  irony,  and 
persiflage. 

The  disease-picture  ordinarily  remains  at  this  degree  of  development. 
Episodically  there  may  be  emotional  delirium  (pathologic  aflfects),  or  even 
explosions  of  furious  mania  with  delirious  ideas  and  hallucinations  due  to 
alcoholic  exces.«es,  or  to  the  restriction  of  excessive  desire,  which,  owing  to 
the  great  emotional  excitability,  easily  occur. 

To  Kirn  is  due  the  credit  of  having  described  the  disturbances 
of  the  somatic  functions  which  accompany  this  condition.  As  a  rule, 
they  belong  to  the  nervous  system  and  are  of  vasomotor  origin,  such 
as  cardiac  palpitation,  congestions  of  the  brain  wäth  soft  and  full 
carotid  pulse  (vascular  paralysis),  alternating  with  vasomotor  spasm, 
paleness,  chilly  feelings  (especially  in  the  extremities),  with  conse- 
quent secretory  troubles  (salivation,  augmentation  of  the  secretion  of 
urine  and  perspiration),  motor  disturbances  (alteration  of  the  inner- 
vation of  the  iris — myosis,  mydriasis,  nystagmus),  and  symptoms  ref- 
erable to  the  vagus  (anorexia,  polydipsia,  and  sometimes  polyphagia). 
These  disturbances  are  individually  extremely  varied,  but  in  a  given 
case  the  symptoms  peculiar  to  that  case  are  quite  as  typic  as  the 
mental  symptoms.  Sleep  is  troubled  and  does  not  last  more  than 
a  few  hours.    Even  when  the  patient  takes  rich  and  abundant  nour- 


PSYCHIC  DEGENERATIONS.  4I9 

ishment,  general  nutrition  falls  considorahly  and  the  body-weight 
remains  much  below  that  maintained  during  the  intervals.  The  los-; 
of  weight  at  the  beginning  and  its  augmentation  after  the  cessation 
of  the  jDaroxysm  take  place  very  rapidly. 

Ordinarily  the  paroxysm  disappears  almost  as  quickly  as  it  cama 
on.  The  change  takes  place  within  a  few  hours  or  days.  "When  the 
intensity  and  duration  of  the  attack  are  considerable,  there  is  left  a 
stage  of  exhaustion  during  which  there  may  be  still  indications  of 
mania  which  last  some  days  or  weeks,  and  which  gradually  disappear 
to  give  place  to  the  interval.  Sometimes  this  period  of  exhaustion 
takes  the  graver  form  of  stupor.  The  consciousness  of  the  patient 
who  has  passed  through  an  attack,  and  who  appears  at  this  time  to 
be  subject  to  mental  inhibition,  may  take  on  painful  features,  though 
this  condition  cannot  be  regarded  as  a  melancholic  terminal  stage. 
I  have  never  observed  such  a  final  stage.  In  the  benign  and  shortest 
form  of  the  periodic  attacks  the  stage  of  postmaniacal  exhaustion 
is  far  from  being  as  intense  or  long,  as  that  which  follows  simple 
mania. 

During  the  interval,  even  after  a  few  attacks,  there  are  lasting 
deviations  from  the  normal  mental  condition;  for  there  is  an  evident 
irritability  of  temper  and  dementia.  Numerous  nervovis  disturbances 
like  those  seen  during  the  paroxysm,  and  the  occasional  recurrence 
of  aura-like  symptoms  (which  are  perhaps  to  be  regarded  as  abortive 
attacks),  and  intolerance  of  alcohol,  prove  that  also  during  the  inter- 
vals the  brain  is  not  sound. 

Whether  a  primary  attack  of  maniacal  insanity  has  the  significance  of 
periodic  mania  is  not  to  be  decided  with  certainty.  The  following  points  indi- 
cate this  with  some  degree  of  probability:  A  quick,  almost  sudden,  outbreak 
with  aura-like  neurotic  s^^mptoms;  the  continuance  of  the  distiu'bance  at  the 
degree  of  maniacal  exaltation  without  passing  on  to  furious  mania  (while  in 
ordinary  non-periodic  mania  the  maniacal  exaltation  is  only  a  short  transi- 
tional period  to  the  height  of  the  disease) ;  a  reasoning  disease-state  Avith  pre- 
dominating irritability  and  marked  delirium  of  action;  impulsive  acts,  accom- 
panied by  pronounced  somatic  functional  disturbances  (neurotic,  gastric).  In 
favor  of  periodic  mania  are  also  shorter  duration  of  the  attack  than  in  ordi- 
nary mania,  when  there  is  a  quicker  attainment  of  the  acme,  shorter  duration 
of  its  greatest  intensity,  and  a  shorter  stage  of  postmaniacal  exhaustion. 
Besides,  there  is  the  remarkably  quick  disappearance  of  excitement,  with  the 
continued  manifestation  of  neurotic  and  mental  anomalies  during  the  interval 
after  the  attack  has  passed  off. 

The  prognosis  of  this  form  of  periodic  insanity,  like  that  of 
periodic  insanity  having  the  character  of  a  psychosis  and  a  longer 
duration  of  the  attacks,  is  decidedly  unfavorable.    In  the  most  favor- 


420  SPECIAL  PATHOLOGY  AND  THERAPY  OP  INSANITY. 

able  case,  under  propitious  conditions  of  life,  tlie  attacks  remain 
separated  by  years.    I  have  never  seen  a  cure. 

Treatment  is  not  powerless  against  tbe  single  attacks.  With 
the  general  indications,  as  they  have  been  pointed  out  in  maniacal 
insanity,  a  treatment  by  jugulation  by  means  of  moderately  large 
or  frequently  repeated  smaller  doses  of  morphine  subcutaneously,  is 
frequently  successful,  but  only  when  it  is  applied  with  the  first  indi- 
cations of  the  oncoming  attack.  If  the  attack  is  fully  developed, 
treatment  by  jugulation  is  impossible,  since  the  attack,  uninfluenced 
by  external  conditions,  runs  its  course  according  to  an  internal  law. 
Still,  the  effect  of  morphine  to  lessen  the  intensity,  especially  in  cases 
of  great  irritability  with  constant  explosions  in  affects  with  painful 
impulsive  thinking,  is  not  to  be  denied,  on  account  of  its  mitigating 
influence. 

Arsenic  and  quinine,  so  effectual  in  a  neurosis  based  upon  malarial  in- 
fection, are  quite  without  effect  in  degenerates  subject  to  periodic  insanity. 
Too,  I  have  never  seen  any  notable  result  from  the  bromides  in  this  form  of 
maniacal  insanitj',  though  Kohn  has  seen  a  jugulating  effect  due  to  potassium 
bromide  (4  to  6  grams)  in  a  case  of  this  kind  in  a  woman.  Mendel  has  pro- 
duced lasting  postponement  of  the  attack  by  means  of  the  injection  of 
ergotine. 

Case  32. — Periodic  mania,  with  long  attacks  and  long  intervals. 

K.,  clerk,  single,  aged  31,  mother  psychopathic.  His  youngest  sister 
suffered  with  convulsions.  Patient  was  well  endowed,  easily  excited,  of  sober 
life.  In- 1861  (puberty?)  and  in  1873  he  had  maniacal  attacks  lasting  several 
months. 

On  November  24,  1873,  without  evident  cause,  the  patient  again  fell  ill. 
The  first  symptoms  were  sleeplessness,  impulsive  thinking,  indecision,  talka- 
tiveness, and  cerebral  congestion.  When  admitted,  Decemljer  11th,  the  patient 
was  at  the  height  of  maniacal  excitement.  He  was  sleepless,  restless,  talka- 
tive to  the  degree  of  incoherence,  gay,  jocular  with  feeling  of  self  much 
intensified,  and  he  complained  that  his  official  position  was  not  sufficiently 
recognized.  He  occupied  himself  with  all  kinds  of  foolish  things  which  he  had 
broiight  with  him  and  which  he  thought  to  be  of  great  value.  He  talked  in 
high-flown  language,  declaimed  poems,  made  speeches,  and  developed  a  mania 
for  writing,  and  when  paper  was  not  at  hand  he  used  the  floor,  the  walls,  his 
collars,  etc.  He  thought  he  was  a  great  singer  and  frequently  tried  his 
metallic  A^oice,  and  he  was  indefatigable  in  ridiculous  jokes  and  foolish  wit. 
Hallucinations  and  delusions  were  not  observed.  There  was  no  deep  disturb- 
ance of  consciousness.  The  patient  always  knew  how  to  explain  plausibly  his 
delirious  actions  (folic  rainonnantc).  Toward  the  end  of  December  there  was 
a  temporary  attainment  of  the  height  of  furious  mania  (flight  of  ideas,  inco- 
herence, impulsive  movement,  and  destructiveness). 

There  were  no  physical  signs  of  degeneration  and  no  anomalies  of  the 
skull.     Owing  to  paresis  of  the  right  abducens,  there  was  convergent  squint. 


PSYCHIC  DJEGENERATIONS.  421 

with  occasional  double  vision.  In  the  right  eye  the  oplithalmoseope  showed  a 
beginning  posterior  staphyloma. 

There  was  no  implication  of  the  sexual  sphere.  Tliere  were  neithei- 
vegetative  disturbances  nor  congestion.  The  pulse-rate  changed  frequently 
and  was  usually  above  100.  Under  treatment  with  digitalis,  baths,  and  injec- 
tions of  morphine,  the  disease-picture  during  the  course  of  1874  sank  to  the 
degree  of  mild  maniacal  exaltation,  with  tendency  to  gather  objects.  There- 
after there  was  a  mild  state  of  mental  exhaustion  lasting  two  months,  out  of 
which  the  patient  came  without  defect. 

On  May  20,  1875,  a  new  attack  without  melancholic  prodromal  stage.  On 
admission  the  patient  presents  the  same  characteristics  as  during  the  first 
attack.  He  goes  about  in  a  gay  mood,  greets  the  physician  -and  his  old  ac- 
quaintances in  a  jovial  way,  and  presents  himself  as  the  functionary  of  a  royal 
insurance  company  and  shows  a  small  horseshoe  magnet  as  the  mysterious 
means  with  which  one  may  establish  the  "symmetry"  for  belonging  to  the 
religion  to  which  he  has  given  his  faith.  The  details  of  the  course  of  this 
attack  are  like  those  of  the  preceding,  only  the  reaso;iing  character  manifests 
itself  .more  clearly  and  the  consecutive  stage  of  exhaustion  has  rather  the 
features  of  moria  (childish  occupation  with  playthings,  silly  manner,  etc.). 

In  December,  1875,  the  attack  passed  off,  but  it  left  behind  slight,  but 
lasting,  mental  weakness,  which  the  patient  himself  remarked,  and  which 
caused  him  to  refuse  to  resume  his  former  occupation. 

At  Christmas  1877,  another  attack,  characterized  by  rapid  sinking  of 
general  nutrition,  sleeplessness,  sensitiveness  to  light  and  noises,  forced  think- 
ing, and  irritability;  and  this  attack  was  a  repetition  of  the  previous  one. 
Sudden  abatement  of  the  attack  in  May,  1878.  Until  the  end  of  June  the 
patient  was  exhausted,  fatigued,  slept  much,  and  then  again  his  previous  state 
was  restored. 

(bj  Periodic  Melanclwlia. 

Periodic  melancholia  is  very  much  less  frequently  observed  than 
the  maniacal  form  of  periodic  insanity.  On  the  other  hand,  it  should 
be  taken  into  account  that  apparently  numerous  cases  of  periodic 
melancholia  have  such  a  mild  course  that  they  never  seek  medical 
aid.  This  explains  likewise  the  great  rarity  of  periodic  melancholia 
in  asylum  practice.  Of  thirteen  such  cases  that  have  come  under  my 
observation,  seven  of  which  w^ere  in  men,  only  four  remained  in  the 
asylum,  and  all  these  were  of  a  severe  form  with  delusions  and  hallu- 
cinations. The  delusions  were  elaborated  upon  a  profound  feeling 
of  personal  unworthiness.  There  existed  violent  precordial  anxiety 
and  disgust  of  life  which  led  to  frequent  attempts  at  suicide. 

The  milder  cases  that  occur  in  private  practice  never  exceed  the 
mild  picture  of  melancholia  without  delusions.  Just  as  in  the  melan- 
cholic phase  of  circular  insanity  later  to  be  described,  in  periodic  mel- 
ancholia without  delusions  the  inhibitory  manifestations  predominate 
over  those  of  spontaneous  psychic  pain.  These  are  mainly  concerned 
with  the  painful  consciousness  of  inhibited  ideation,  volition,  and 


423  SPECIAL  PATHOLOGY  AND  TIIE!^\PY  OF  IXSAXITY. 

feeling:  i.e.,  Avith  a  want  of  coloi-ijio;  of  ideas  willi  feelings  (psyrhic 
anesthesia).  The  patient  gives  himself  np  to  painfnl  rellection  con- 
cerning this  absence  of  accustomed  feeling,  and  asks  whether  or  not 
he  is  human. 

In  all  cases  of  periodic  melancholia  there  are  pronounced  somatic 
sj'mptoms  in  the  mental  disease-picture — sleeplessness,  headache, 
vertigo,  contraolod  arteries,  usually  with  a  frcipient  jiulse,  anorexia, 
gastric  disturbances,  rapid  fall  of  genei'al  iiulriiiDn,  cessation  of  the 
menses,  jjaralgias,  neurasthenic  sjanptoms,  and  sensory  and  vasomotor 
disturbances-^all  forming  an  integral  part  of  the  general  disease-pic- 
ture. Once  I  saw  herpes  zoster  over  the  distribution  of  the  left  supra- 
orbital nerve.  The  beginning  of  the  attack,  which  often  came  on 
with  gastric  disturbances,  and  its  disappearance,  always  took  place 
suddenly.  The  duration  of  the  attacks  was  from  six  weeks  to  several 
months.  I  could  not  make  out  either  a  maniacal  prodromal  or  final 
stage  (Kirn).  ' 

In  all  my  cases  I  found  pronounced  and  usually  hereditary  taint. 
The  prognosis  is  unfavorable.  Eecovery — i.e.,  freedom  from  attacks 
during  years — I  Avas  never  able  to  attain.  It  seems  that  with  increas- 
ing age  the  attacks  became  more  protracted,  without,  however,  be- 
coming especially  more  severe.  In  several  cases  signs  of  mental 
weakness  early  appeared,  and  during  the  interval  slight  psychic  de- 
pression could  be  discovered.  The  use  of  opium  and  morphine  in 
my  observation  brought  about  a  symptomatic  result,  but  never  had 
any  jugulating  or  shortening  influence.  The  bromides  in  combina- 
tion with  autipyrin  and  codeine  often  gave  relief.^ 

Case  33. — Periodic  melancholia. 

Mrs.  D.,  aged  35.  On  her  mothei-'s  side  she  comes  of  a  tainted  family. 
Her  mother's  brother  was  insane,  her  mother  neuropathic  and  to^vard  the  end 
of  her  life  insane.  All  the  brothers  and  sisters  of  the  patient  suffer  with  neu- 
ropathic conditions;  one  sister  became  insane  during  the  puerperal  state. 
Patient  was  neuropathic,  and  at  the  age  of  four  had  "inflammation  of  the 
brain,"  but  she  developed  well,  was  gay,  sociable,  and  mentally  bright.  At  the 
age  of  eighteen  she  was  married.  During  the  first  period  of  her  married  life 
the  patient  suffered  much  with  vaginismus.  Without  further  accidents  she 
bore  seven  children   (1SG5,  1869   [February],  1870   [March],  1871    [May],  1S73, 


1  B   Sod.    brom., 9.0 

Antipyrin, 3.0 

Codeine  hydrochl.,      .......       0.3 

Aq.  dest.,  130.0 

Syr.  menth.  pip., 20.0 

M.     Sig. :    Two  to  seven  teaspoonfuls  daily. 


PSYCHIC  DEGENERATIONS.  403 

1870  [June],  1877  [October]).  In  her  second  cliildljcd,  in  wliicli  tlie  patient 
nursed  her  baby,  after  a  mental  sliock  (death  of  a  sister  five  weeks  after  her 
child  was  born),  the  first  attaclv  of  melancholia  occurred,  and  lasted  five 
months,  until  the  beginning  of  the  next  pregnancy.  Tliis  attack  was  not  con- 
nected witlr  the  return  of  the  menses.  Other  causes  than  those  given  were 
not  discoverable.  The  marital  and  social  relations  were  the  most  favorable 
possible. 

According  to  the  patient's  assurance,  other  typically  similar  attacks  were 
observed,  differing  only  in  intensity  and  duration:  1870,  from  March  till  Sep- 
tember; 1871,  March  to  August;  1872,  April  to  August;  1873,  March  to 
August;  1874,  September  to  July,  1875;  1875,  September  to  April,  187G;  1870, 
September  to  May,  1877;  1877,  September  to  April,  1878;  1878,  October  to 
April,  1879;    1879,  October  to  March,  1881. 

I  first  saw  the  patient  in  December,  1880,  when  she  came  to  consult  me 
on  account  of  the  unusual  length  of  the  attack  she  was  svvffering  from  at  the 
time. 

The  attacks  begin  suddenly  in  the  midst  of  perfect  mental  and  physical 
health.  The  first  signs  are:  violent  sexual  excitement,  v\^hich  is  not  present 
in  the  intervals,  with  painful  impulse  to  onanism;  further,  loss  of  appetite, 
sleeplessness,  palpitation.  Pronounced  mental  inhibition  and  depression 
quickly  come  on.  The  patient  feels  herself  without  interest,  incapable  of 
pleasure,  unspeakably  luihappy,  and  tired  of  life.  Life  seems  to  her  a  heavy 
burden,  and  it  pains  her  to  think  that  she  has  become  indifferent  to  her  duties 
as  mother  and  housewife.  But  she  is  also  incapable  of  fulfilling  them.  She 
is  devoid  of  energy,  depressed,  incapable  of  any  activity,  fatigued,  and  ex- 
hausted, especially  in  the  morning  after  she  has  passed  a  sleepless  night.  She 
has  the  complete  despairing  sense  of  her  disease  and  of  her  mental  incapability. 
For  months  at  a  time  she  does  not  sleep  and  she  is  forced  to  take  chloral 
hydrate.  She  is  tortured  with  thoughts  that  she  will  never  get  well,  and  longs 
for  death  as  a  deliverance.  Occasionally  there  are  reactive  outbreaks  of  de- 
spair, which  then  end  in  an  outburst  of  weeping. 

She  is  without  appetite,  but  must  force  herself  to  eat,  feels  oversatiated 
and  a  distressing  dryness  in  the  throat.  There  is  constipation;  the  menses 
are  regular,  but  scanty.  Almost  all  the  time  the  patient  suffers  with  a  dis- 
tressing feeling  of  pressure  in  the  back  of  the  head,  numbness  in  the  hands, 
pressure  in  the  feet,  and  pain  along  the  inner  surface  of  the  thighs. 

Suddenly  one  day  the  painful  condition  disappears.  She  sleeps  again,  has 
appetite,  takes  pleasure,  and  feels  more  than  happy,  though  this  feeling  of  de- 
liverance from  the  disease  cannot  be  regarded  as  a  maniacal,  final  stage.  At 
least,  at  this  time  she  becomes  again  a  very  intelligent  woman,  and  is  re- 
garded as  such  by  her  family.  Now  the  body-Aveight  increases  rapidly,  Avhich 
in  the  beginning  of  the  attack  sank  rapidly  and  which  during  the  whole  of  the 
attack  remained  at  not  more  than  59  to  61  kilograms,  until  her  normal  weight 
of  about  70  kilograms  is  attained.  During  the  intervals  the  patient  is  phys- 
ically and  mentally  well,  only  she  is  now  and  then  distressed  by  the  thought 
that  the  fatal  disturbance  may  sooner  or  later  come  on  again. 

The  last  attack,  which  is  described  in  a  letter  dated  toward  the  end  of 
March,  1881,  was  protracted,  owing  to  the  fact  that  at  the  time  of  the  pre- 
sumed termination  of  it  her  father  (April,  1880)  and  other  members  of  the 
familv  died,  and  she  had  also  other  emotional  shocks. 


424  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  patient  is  a  wonian  of  niitUlle  height,  ■without  signs  of  degeneration 
and  without  disease  of  the  vegetative  organs.  At  the  time  I  examined  her  in 
December,  1S80,  tlie  turgor  vitalis  was  veiy  mnch  reduced;  the  pulse  in  the 
radials  and  carotid  was  very  small,  easily  compressible.  The  patient  looked 
ten  years  older  than  she  really  was.  Her  nervous,  depressed  countenance  be- 
traj-ed  the  painful  emotional  state. 

The  tongue  was  clean,  but  was  said  to  be  coated  at  times.  There  were 
no  signs  of  anemia.  Gynecologic  examination  gave  a  negative  result.  Natu- 
rally the  patient  had  tried  all  remedies.  Gynecologic  interference  on  account 
of  the  genital  neurosis;  cold-water  cure.  Fi-anzensbad  had  a  bad  effect. 
Quinine,  arsenic,  atropine,  opium,  potassium  bromide  had  been  of  no  use.  Only 
lukowann  baths  had  a  quieting  effect,  which  was  sometimes  hypnotic.  The 
patient  was  most  at  peace  in  the  quiet  of  the  country.  The  patient  was  never 
in  an  asylum. 

(c)  Periodic  EaUacinatory  Insanity. 

Primär}^  hallucinator}-  insanity  occurring  periodically  is  very 
rare,  when  menstrual  cases  and  those  of  sympathetic  origin  are 
ignored. 

Mendel  has  reported  three  cases  of  periodic  hallucinatory  insan- 
ity. The  clinical  picture  and  the  comparison  of  the  single  attacks  do 
not  differ  from  cases  that  are  not  periodic;  so  that  only  the  general 
course,  and  especially  the  recurrence  of  typically  similar  attacks  at 
approximately  similar  intervals,  make  the  diagnosis  possible. 

Case  34. 

Mrs.  H.,  aged  54,  wife  of  an  official.  She  was  always  irritable  and  nerv- 
ous, and  mentally  below  the  average,  coming  of  a  family  said  to  be  tainted. 
She  had  children:  in  1868  and  1870.  She  has  been  in  the  climacteric  a  year 
(irregularity  of  the  menses,  with  absence  of  them  for  months  at  a  time;  be- 
ginning obesity,  rushing  of  blood  to  the  head,  great  nervousness,  emotionality, 
irritability).  In  September  and  October,  1883,  she  had  much  trouble  on  ac- 
count of  the  lack  of  success  of  her  sons  in  studies,  and  unpleasant  household 
relations. 

November  10,  1883,  she  complained  of  great  feeling  of  malaise,  violent 
headache,  was  irritable,  excited,  and  complained  of  being  neglected  by  her 
liusband.  She  threatened  to  leave  the  house,  was  restless,  easily  frightened, 
and  the  night  of  the  11th  she  was  sleepless.  In  her  medicine  she  detected 
poison  and  said  that  the  physician  and  her  husband  were  poisoners.  She  de- 
stroyed a  lamp  because  it  was  poisoned,  and  tried  to  run  away.  She  became 
aggressive  toward  her  relatives  and  could  not  be  cared  for  at  home. 

November  18tli  she  w^as  brought,  delirious  and  confused,  to  the  clinic, 
where  she  took  those  around  her  to  be  enemies,  thought  she  was  at  home,  and 
was  much  frightened,  thought  that  she  was  being  poisoned,  complained  of  bad 
odors,  and  demanded  that  the  emperor  come  to  protect  her  from  her  husband 
and  son,  who  were  poisoners  and  must  be  burned.  Her  son  was  a  villain;  he 
made  noise  with  electricity  and  gave  her  shocks.  Everything  gave  forth  foul 
odors,  was  poisoned,  and  full  of  electricity.  She  wished  to  be  divorced  from 
her  poisoning  husband.     She  would  soon  die.     The  emperor  had  invited  her. 


PSYCHIC  DEGENERATIONS.  425 

The  delirium  became  constantly  more  incoherent;  sleeplessness,  refusal  of 
food.  Pulse  up  to  120,  no  fever,  no  congestion,  no  disease  of  the  vegetative 
organs.  Eaths  and  injections  of  morphine  prescribed.  In  the  beginning  of 
December  the  patient's  consciousness  cleared.  She  thinks  she  must  have  been 
confused,  has  true  memory  for  the  events  of  the  disease,  is  mentally  decidedly 
exhausted,  and  with  good  sleep  and  appetite  rapidly  recovers.  Discharged  re- 
covered, December  26,  1883.  Second  admission,  February  18,  1885.  During  the 
interval  the  patient  had  been  Avell,  and  had  had  her  menses  now  and  then  until 
October,  1884,  and  she  felt  well  and  spoke  without  shyness  of  her  former 
attack. 

In  the  beginning  of  February,  1885,  she  became  somewhat  more  emotional 
and  irritable,  because  one  of  her  sons  did  not  study  satisfactorily.  February 
14th  she  was  disturbed  in  her  sleep  by  a  fire-alarm  at  night,  and  on  the  15th 
by  a  storm.  On  the  17th  she  lost  appetite,  spoke  in  monosyllables,  and  was 
preoccupied  while  playing  cards.  On  the  18th,  after  a  bad  night,  she  com- 
plained of  feeling  unwell  and  headaehe,  just  as  in  the  beginning  of  the  first 
attack;  so  that  they  were  anxious  about  her.  During  the  18th  the  patient 
was  restless,  apprehensive,  and  wished  to  go  to  relatives  in  a  neighboring 
town.  Her  husband  accompanied  her  there.  While  on  the  way,  at  a  station 
where  they  had  to  change  trains,  she  became  delirious,  and  on  the  platform 
she  asked  the  officer  to  arrest  her  husband  for  he  had  poison  and  dynamite  on 
his  person  and  had  already  poisoned  her  twice.  The  poison  could  be  seen  in 
her  hands.  She  should  be  immediately  submitted  to  autopsy  in  order  that 
the  guilt  of  her  husband  could  be  proved. 

She  was  admitted  to  the  clinic  the  second  time  on  February  18,  1885. 
The  patient  was  delirious,  excited,  and  said  her  husband  was  a  poisoner  and 
her  son  an  incendiary.  They  wanted  to  poison  her,  burn  her;  the  bishop  must 
be  called,  as  she  wished  to  confess  and  make  her  will.  Here  everything  is 
haunted,  everything  is  poison.  It  was  necessary  that  the  house  be  surrounded 
with  soldiers.  Refusal  of  food  could  not  be  overcome  on  account  of  fear  of 
poison.  Great  thirst  at  night.  The  gas  must  be  poisoned;  water  smells  and 
tastes  bad.  The  patient  is  sleepless,  disturbed,  hostile,  fears  being  blown  into 
the  air  by  an  explosion. 

On  March  16th  the  psychosis  disappears.  The  patient  was  taken  from 
the  institution  on  March  21st  by  her  husband,  discharged  recovered.  She  has 
perfect  memory  for  all  the  events  of  her  sickness. 

The  patient  remained  normal  and  well  until  March  10,  1886,  when  she 
suddenly,  and  without  any  external  cause,  fell  sick  in  exactly  the  same  way. 
In  the  institution  the  hallucinatory  insanity  followed  the  same  course  as  in 
the  previous  attacks.  Toward  the  end  of  April,  1886,  quick  recovery;  well 
until  May  18,  1887.  New  attack  exactly  like  the  others,  lasting  until 
May  20th. 

Fifth  attack  from  November  15,  1887,  imtil  the  end  of  January,  18S8. 

Sixth  attack  from  February  11th  until  the  beginning  of  March,  1888. 

Seventh  attack  from  the  end  of  March  until  the  beginning  of  April,  1888. 

Eighth  attack  from  August  25,  1888,  imtil  the  end  of  September. 

Ninth  attack  from  the  middle  of  November  until  the  middle  of  Decem- 
ber, 1888. 

Since  this  time  the  attacks  occur  more  frequently;  and  since  the  fifth 
attack  rapid  increase  of  mental  weakness.    The  attacks  are,  as  before,  typic. 


4-2G  SPECIAL  PATHOLOGY  AND  THERAPY  OE  INSANITY. 

The  later  ones,  liowever,  arc   charaeteiizod  by   ct>iifu8iuii   and   iiuillitudiiums 
hallucinations,  especially  those  of  smell. 

The  patient  was  sent  to  the  local  inslilution  for  the  insane,  where  the 
attacks  continue,  and  the  mental  weakness  is  said  to  have  taken  a  predominat- 
ing place  in  the  picture. 

(d)  Circular  Iiisaiiit!/. 

In  tin's  form  there  is  an  allcrnating  cyclic  occnrrcncc  of  mclan- 
cliolic  and  maniacal  conditions, which,  in  distinction  from  melancholia 
l)assing  on  into  mania,  takes  place  typically  during  a  longer  period, 
indeed,  even  throughout  the  whole  of  life  (folie  circulaire — Falret; 
folie  ä  dovhle  forme — Baillarger). 

The  cycle  of  two  states  recalls  the  fact  that  in  many  hereditarily  tainted 
individuals  there  is  a  periodic  alternation  of  depression  and  exaltation  that  is 
haliitual;  and  it  is  possible  that  circular  insanity  should  be  regarded  as  an 
intensification  of  this  jjathologic  alternation  of  feeling.  In  all  cases  where  the 
ancestry  could  be  investigated  it  has  shown  itself  to  be  a  form  of  hereditary 
degenerative  insanity,  the  outbreak  of  which  occurs  especiallj'  at  the  time  of 
puberty  or  in  the  climacteric.^ 

According  to  Ealret's  observation,  with  which  that  of  others  and  my  own 
are  in  accord,  it  affects  women  especially.-  Not  infrequently  the  development 
of  circular  insanitj^  is  preceded  for  years  by  attacks  of  simple  or  periodic 
mania  or  melancholia. 

Circular  insanity  begins,  for  the  most  part,  as  melancholia,  less 
frequently  as  mania.  The  initial  disease-picture  is  distinguished 
from  the  later  manifestations  by  unusual  intensity  and  duration. 
For  the  most  part,  the  opposite  state  follo-\vs  immediately  upon  its 
forerunner,  and  in  a  few  cases  these  states  are  separated  by  a  lucid 
interval. 

The  course  of  the  malady  is  made  up  of  an  alternation  of  the 
two  states  which  form  the  cycle,  and  which  usually  are  sharply  de- 
fined one  from  the  other  and  less  frequently  pass  one  into  the  other. 
This  last  possibility  is  found  more  in  cases  in  which  the  duration  of 
the  phases  is  long.  There  may  be  observed  also  a  phenomenon  noted 
by  Meyer.  The  temporary  elementary  symptoms  of  the  opp  )site 
state  to  that  of  the  picture  presented  may  arise  in  the  melancholic  or 
maniacal  sta2;e.     The  course  of  the  melancholic  and  the  maniacal 


^Ball,  Annales  Medico-Psychologiques,  ISSO,  September,  page  192,  men- 
tions, however,  the  case  of  an  untainted  man  in  whom  the  malady  arose  after 
injury  to  the  head  (during  twenty-seven  years,  ten  months  of  mania  always 
followed  by  two  years  of  melancholic  depression). 

'  In  literature,  of  48  cases,  28  were  women,  20  men.  In  my  own  observa- 
tion of  24  cases,  16  were  women  and  8  men. 


PSYCHIC  DEGENERATIONS.  427 

states  Tnay  at  any  time  he  inlorniptcd  hy  a  lucid  interval;  Liit  tlio 
occurrence  of  the  interruption  is  really  neither  so  regular  nor  so 
frequent  as  is  stated  by  many  authors.  It  occurs  most  frequently 
after  one  or  more  t'ycles  have  taken  place,  and  then  as  an  intermedi- 
ary stage  between  two  phases;  seldom  does  it  ap[)oar  as  an  interrup- 
tion of  a  maniacal  or  melancholic  phase. ^ 

The  duration  of  the  lucid  interval  is  shorter  and  less  pure  in 
case  it  occurs  between  the  two  phases.  It  is  longer  when  it  separates 
tVo  cycles. 

The  duration  of  the  whole  cycle,  as  of  the  phases  which  rnakf; 
it  "up,  is  variable  and  not  infrequently  dependent  upon  external  con- 
ditions, both  in  different  cases  and  in  the  same  patient. 

There  are  cases  of  circular  insanity  in  which  the  single  cycle 
lasts  a  few  weeks  and  others  in  which  it  lasts  months  or  years.  As  a 
rule,  the  melancholic  phase  lasts  longer  than  the  maniacal.  If  there 
be  a  lucid  interval,  this  is  of  shorter  duration  than  the  other  phases. 
There  are  cases,  especially  those  of  long  duration  of  the  stages,  in 
which  this  remains  almost  identical,  while  in  other  cases  short  and 
long  phases  alternate. 

According  to  my  observation,  the  melancholic  and  maniacal 
phases  of  circular  insanity  present  nothing  specific.  In  the  majority 
of  cases  the  phases  do  not  become  more  intense  than  in  mere  melan- 
cholic depression  or  maniacal  exaltation,  and,  owing  to  the  exquisite 
degenerative  foundation,  these  have  a  reasoning  coloring.  For  this 
reason  we  meet  circular  insanity  much  more  frequently  in  private 
practice  than  in  the  asylum.  Only  very  infrequently  are  the  func- 
tionally severe  forms  of  mielancholic  stupor  or  of  furious  mania  with 
delusions  and  hallucinations  observed.  When  once  the  condition  is 
developed,  it  usually  remains  the  same,  even  though  it  does  not  re- 
produce itself  with  photographic  faithfulness,  though  all  attacks 
are  essentially  alike,  presenting,  at  most,  differences  in  the  duration 
or  intensity  of  the  phases  of  the  cycle. 

In  general,  it  may  be  said  that  the  longer  the  duration  of  the 
phases  the  milder  will  be  the  form  of  disease. 

The  diagnosis  of  circular  insanity  can  only  be  made  after  ob- 
servation of  its  complete  course.    The  following  peculiarities  raise  a 


'■Cases  in  which  maniacal  and  melancholic  phases  follow  one  another  im- 
mediately, and  which  are  separated  from  the  next  cycle  by  an  interval,  a-re 
usually  called  folie  ä  douMe  forme.  Cases  in  which  one  phase  is  separated 
from  the  other  by  an  interval  are  called  circular  insanity.  Cases  in  which 
there  is  no  interval  are  called  alternating  insanity.  This  alternating  insanity 
is  usually  made  up  of  quite  ephemeral  phases. 


428  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

suspicion  of  tliis  disease:  a  mmiiacal  or  melancholic  attack,  if  it  oc- 
cnrs  suddenly  at  the  time  of  puberty  or  in  the  climacteric  and  remains 
for  weeks  at  tlie  same  mild  degree  of  development;  a  melancholic  or 
maniacal  condition,  presenting  symptoms  of  the  opposite  phase  epi- 
sodically.- Of  the  same  value  are  the  great  disturbance  of  general 
health,  the  poor  pulse,  sunken  turgor  vitalis,  rapid  loss  of  weight;  do- 
pressed,  aged  look;  the  loss  of  mimic  expressio]i.  aiul  the  innuiuorablo 
neuralgic  and  paralgic  troubles  in  the  melancholic  pliase;  and,  on 
the  contrary,  the  fresh,  pleasant  expression  (Meyer);  the  full,  strong 
pulse;  the  unusually  increased  turgor  vitalis,  in  the  maniacal  picture. 
Emmerich  (op.  cil.)  calls  attention  to  the  fact  that,  in  the  melan- 
cholia that  is  a  phase  of  circular  insanity,  the  depression  is  much 
less  a  spontaneous  painful  state  than  in  genuine  melancholia,  and 
is  usually  a  state  of  reactive  painful  consciousness  of  mental  inhi- 
bition. 

Since  circular  insauity  is  in  most  cases  profoundly  consti- 
tutional, there  is  but  little  hope  of  cure.  It  is  most  to  be  expected 
whcTi  the  phases  are  short;  when  they  are  long,  they  occur  usually 
with  fatal  regularity  to  the  end  of  life,  though  with  increase  of  age 
the  attacks  usually  grow  milder.  Even  in  these  cases  long  inter- 
missions may  occur.  When  the  disease  has  lasted  for  a  long  time, 
evidence  of  psychic  weakness  appears,  though  I  have  never  seen  a 
tertnination  in  actual  dementia. 

The  treatment  must  be,  in  the  main,  symptomatic. 

In  a  few  cases  of  a  short  cycle  the  salts  of  bromine  have  appeared  to  be 
not  without  efl'ect.  Still  more  efl'ectiial  have  been  opium  and  morphine  used 
subcutaneously.  Kretz  once  was  able  to  attain  cessation  in  two  cases  of  mild 
character  in  the  maniacal  phase  by  the  use  of  hyoscyamine. 

The  observation  of  Schule,  according  to  which  the  successful  treatment  of 
uterine  disease  in  a  patient  suffering  from  circular  insanity  had  an  abortive 
effect  upon  the  psychosis,  points  to  a  possibility  of  peripheral  irritation  and 
the  importance  of  removing  it.  It  is  also  worthy  of  attention  that  Dittmar, 
in  the  asylum  at  Klingenmiinster,  reports  the  experience  that  rest  in  bed  in 
the  melancholic  stage  put  off  the  beginning  of  the  maniacal  stage  and  made 
the  course  of  the  latter  milder. 

Case  35. — Circular  (melancholico-maniacal)  insanity;  phases  of 
several  months'  duration. 

R.,  aged  20,  student,  was  admitted  to  the  asylum  February  23,  1878. 
Father  tabetic;  two  brothers  neuropathic  and  excitable.  One  is  said  to 
have  suffered  with  contrarj'  sexual  feeling.  The  patient  had  never  been 
seriously  ill,  though  nervous  and  excitable.  He  had  to  give  up  the  study  of 
medicine  because  he  could  not  grow  accustomed  to  the  sight  of  corpses.  He 
early  gave  himself  to  onanism,  and  since  years  it  had  been  noticed  that  he 


PSYCHIC  DEGENERATIONS.  429 

was  languid  and  without  self-confidence  in  society.  In  the  fall  there  were 
symptoms  of  neurasthenia  (l.assitudc,  easily  fatigued,  feelings  of  weight  and 
drawing  in  the  extremities,  difficulty  of  thought,  palpitation,  etc.).  He  be- 
came depressed  and  hypochondriac,  thought  his  palpitations  were  due  to  heart 
disease,  and  consulted  a  pliysician,  who  conlirmed  this  diagnosis.  He  became 
retiring,  for  he  thought  he  noticed  that  everybody  knew  liis  secret  vice.  In 
the  beginning  of  February,  1878,  after  feeling  tired,  ill,  and  mentally  incapable, 
he  became  apprehensive,  excited,  and  played  the  part  of  despair  in  a  theatrical 
way  bordering  upon  hallucinatory  insanity.  He  could  not  sleep,  he  tossed 
about  in  bed,  and  complained  that  he  could  no  longer  think,  feeling  that  he 
had  ruined  himself  mentally  and  physically  by  onanism.  He  wanted  his 
genitals  examined,  for  they  were  clianged  in  color.  Violent  feelings  of  fear, 
and  sensations  as  if  his  heart  were  being  compressed,  and  now  and  then  un- 
pleasant olfactory  sensations. 

On  admission  the  patient  was  at  the  heiglit  of  passive  melancholia,  retir- 
ing, feeling  great  mental  pain,  fearful,  and  inhibited  in  movement,  speech,  and 
thought.  By  fragmentary  expressions  it  was  possible  to  learn  his  state  of 
despair  due  to  his  painful  state  of  inhibition  and  his  pangs  of  conscience  be- 
cause of  his  vice,  Avhich  had  made  him  a  sinner.  As  a  reaction  to  this  painful 
state  of  consciousness  there  was  evidence  of  how  he  had  scratched  himself  all 
over  the  body.  The  patient  is  well  formed,  but  physically  exhausted,  anemic. 
He  is  hollow-eyed,  and  his  gait  is  shuffling  and  uncertain.  His  expression  is 
anxious,  confused,  the,  pupils  are  dilated  and  react  slowly,  the  face  somewhat 
congested  and  dark,  the  pulse  small,  130  to  160.  The  cardiac  region  and  the 
epigasti'ium  are  in  marked  movement,  and  the  smaller  arteries,  like  the  max- 
illary, show  visible  pulsation.  The  heart-sounds  are  pure  and  the  heart-dull- 
ness not  increased.  A  slight  degree  of  exophthalmos.  No  disturbance  of  the 
vegetative  functions.  No  spermatorrhea;  no  sensory  or  motor  disturbances; 
negative  findings  in  the  fundus  of  the  eyes.  (Ordered:  rest  in  bed,  ice-bag 
over  the  heart,  digitalis,  milk  diet.) 

The  patient  remains  extremely  inhibited,  mentally  tortured  with  pre- 
cordial distress,  and  profoundly  disturbed.  Only  broken  sentences  are  heard: 
"Oh,  my  poor  mother,  my  head,  this  is  going  crazy!"  The  patient  is  unable 
to  think  out  any  sentence;  the  chain  of  thought  is  constantly  broken. 
Neither  digitalis  nor  quinine  in  large  doses  reduces  the  pulse-rate.  Onlj^  after 
baths  prolonged  to  three  hours  does  the  pulse  drop  to  100  and  sleep  come  on. 
With  the  slightest  emotion,  and  with  every  sigh  and  every  movement  of  the 
body,  the  pulse  immediately  becomes  very  rapid.  The  vegetative  functions  are 
normal  and  sufficient  food  is  taken.  After  the  evening  bath  the  patient  is 
always  somcAvhat  freer.  He  then  complains  of  his  horrible  precordial  distress 
and  mental  inhibition  and  does  not  know  whether  he  is  alive  or  whether  he 
can  read  and  write.  He  has  distressing  vacancy  in  his  head,  and  fears  he  is 
going  crazy.  During  the  rest  of  the  day  he  is  very  restless,  anxious,  and 
mentally  inhibited.  At  the  same  time  there  is  great  impulse  to  onanism, 
which  can  only  be  overcome  by  constant  care  day  and  night.  At  times  the 
inhibition  is  intensified  to  slight  stupor  and  mutism.  In  freer  moments  the 
patient  begs  to  be  given  poison,  to  be  shot;  his  head  is  so  benumbed  he  can- 
not think;  he  has  destroyed  his  brain  by  his  vice  and  can  no  longer  endure  it. 
Now  and  then  complaint  of  foul  odors,  headache,  dullness,  and  pains  in  hig 
extremities. 


430  SPECIAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

lu  May,  with  decided  increase  of  flesh  and  reduction  of  the  pulse  to  about 
100,  the  patient  became  freer  mentally  and  in  movement.  He  complains  of  the 
time  lost  in  his  studies,  and  wishes  now  to  regain  control  of  himself  and  give 
up  his  vice.  Everything  seems  like  a  dream  to  him.  After  several  relapses, 
every  one  of  which  could  be  referred  to  renewed  onanism,  convalescence  was 
established.  The  diagnosis  was  melancholia  upon  a  neiu-asthenic  foundation, 
and  the  patient"  was  discharged  presenting  all  the  signs  of  recovery,  though 
with  a  pulse  of  120,  on  July  23,  187S. 

As  early  as  July  2Gth  the  correctness  of  the  diagnosis  was  called  in 
question,  for  the  patient  showed  symptoms  of  maniacal  exaltation,  which, 
owing  to  the  fact  that  the  melancholia  had  disappeared,  was  not  a  melan- 
cholic prodromal  stage  of  mania;  and,  further,  considering  the  reasoning 
cliaracter  of  the  mania  and  the  fact  that  it  did  not  increase  in  intensity  to 
finious  mania,  could  scarcely  be  considered  anything  less  than  a  phase  of  a 
circular  mental  distin-bance.  The  patient  became  joyous,  talkative,  restless, 
went  to  Menna  with  500  florins,  and  there  made  many  useless  purchases  and 
committed  excesses  of  all  kinds. 

Just  as  he  was  about  to  extend  his  journey  to  Paris  and  London,  he  was 
brought  back  again  to  the  institution  on  August  20,  1878.  He  was  mimically, 
mentally,  and  somatically  an  entirely  diff'erent  personality  than  when  first  ad- 
mitted. His  expression  was  lively,  joyous,  and  the  face  slightly  red,  the  eyes 
shining,  general  nutrition  excellent,  and  the  turgor  vitalis  increased.  The 
patient  felt  better  than  he  ever  had,  boasted  of  his  knowledge  and  his  power 
of  thought  and  memory,  and  the  remarkable  examinations  he  said  he  had 
passed.  He  entertained  the  idea  of  studying  philosophy,  law,  and  medicine  at 
once,  and  to  matriculate  simultaneously  in  Vienna  and  Paris.  He  said  that  he 
was  a  candidate  for  the  Eeichstag  and  for  a  diplomatic  career,  and  regarded 
the  fulfillment  of  this  ambition  as  easy.  He  was  acquainted  with  and  knew 
everything;  his  comprehension  Avas  lightning-like.  He  was  the  most  generous 
man  and  the  kindest  relative,  although  he  talked  about  his  parents  in  the 
grossest  way  because  they  sent  him  no  money;  he  Avas  a  friend  of  the  most 
perfect  character.  There  was  great  intensification  of  feeling  of  self,  which  was 
constantly  being  increased  by  the  great  facility  in  the  operation  of  the  psycho- 
motor processes.  Gay  mood,  optimistic  comprehension  of  everything,  maniacal 
feeling  of  well-being.  Little  sleep,  planless  activity,  which,  with  true  furor 
and  abnormal  haste,  mixes  everything  up  and  brings  nothing  to  conclusion. 
Intensified  ideational  activity;  disconnected,  facilitated,  and  rapid  ideation; 
constant  writing  and  talking,  allowing  no  one  else  to  get  in  a  word,  losing  him- 
self in  hundreds  and  thousands.  His  diction  is  affected,  high  sounding,  marked 
by  strong  expressions  and  high-flown  words.  Great  desire  for  alcohol  and 
tobacco,  while,  when  in  health,  the  patient  has  no  such  desire. 

On  the  evening  of  September  2,  1878,  without  any  cause,  in  the  midst  of 
this  maniacal  picture  there  was  a  state  of  profound  painful  emotion,  with 
decidedly  disturbed  consciousness,  violent  tccdium  viUc,  and  an  attempt  to 
strangle  himself.  The  following  morning  the  patient  had  no  idea  how  he  had 
fallen  into  this  condition,  and  appeared  again  at  the  height  of  maniacal 
exaltation.  He  wished  to  go  to  the  Paris  Exposition,  wrote  page  after  page 
of  his  biography,  blustered,  quarreled,  showed  sharpness  in  logic  and  in 
dialectic,  was  witty,  ironic,  sang,  whistled,  made  all  sorts  of  jokes,  and  would 
know  how  to  run  the  whole  house  if  he  only  could.    He  was  always  quick  and 


PSYCHIC  DEGENERATIONS.  431 

able  to  excuse  and  explain  everything.  His  jovial  mood  was  inexhaustiljlc, 
even  when  toward  the  end  of  September  strict  isolation  was  ordered. 

On  the  physical  side  there  was  tendency  to  congestion;  pulse  over  100 
and  usually  120;  myotic  pupils;  fresh,  somewhat  dusky,  appearance  of  the 
face;  and  splendid  condition  of  general  nutrition.  Toward  the  middle  of 
December  gradual  abatement  of  the  mania  with  lasting  reduction  of  the  pulse- 
rate  to  80  or  90.  On  January  1,  1870,  the  patient  ran  away  and  went  home, 
still  in  a  maniacal  condition.  In  the  beginning  of  February  melancholia  ap- 
peared again,  which,  however,  was  not  nearly  so  intense  as  in  the  first  attack, 
and  remained  at  the  level  of  melancholia  without  delusions,  with  slight  pre- 
cordial distress;  and  this  is  said  to  have  passed  away  toward  the  end  of 
June. 

The  beginning  of  July  by  chance  I  saw  the  .patient.  He  appeared  lucid: 
i.e.,  neither  melancholic  nor  maniacal.  Toward  the  end  of  July  mania  again 
came  on.  The  patient  again  wandered  about  in  traveling,  began  to  swindle, 
commit  excesses,  Avasted  money  and  clothing,  sent  pressing  letters  home  with 
a  threat  to  shoot  himself  if  money  was  not  immediately  sent  to  him.  In  hotel 
registers  he  signed  himself  as  Count  Kristalnig,  Doctor  of  Laws  and  Medicine. 
On  August  27,  1879,  he  had  to  be  sent  to  the  asylum  at  K.,  from  which  he 
escaped  on  October  26th  in  a  very  cunning  manner.  The  case-book  in  this  insti- 
tution, which  was  kindly  submitted  to  me,  showed  that  the  disease-picture 
was  typic  and  corresponded  exactly  with  the  maniacal  state  that  had  been 
first  observed. 

In  addition  to  these  clinical  joictures  manifesting  themselves  in 
cj^clic  alternation  of  melancholia  and  mania^  there  may  be  mentioned 
a  rarer  form  which  shows  itself  in  the  typic  alternation  of  mania-like 
states  of  excitement  and  stupor. 

Kahlbaum  has  employed  some  cases  of  this  kind  in  his  description  of 
"Catatonia."  Dittmar,  who  in  general  attributes  only  a  secondary  value  to 
the  mental  anomaly,  also  mentions  tliese  cases  of  circular  insanity,  which  are 
characterized  by  regular  alternation  of  states  of  mania  and  stupor. 

This  variety  is  rarer  than  the  foregoing.  It  manifests  itself  almost  ex- 
clusively in  males  at  the  time  of  puberty  or  immediately  thereafter.  In  all 
cases  that  have  come  under  my  observation  there  were  signs  of  taint.  The 
exciting  causes  Avere  excesses  in  onanism  or  emotional  shocks;  a  prodiromal 
stage  of  melancholic  depression  lasting  days  or  months  preceded  the  circular 
insanity.  This  began  with  stupor  or  maniacal  excitement,  Avhich  thereafter 
alternated.  Sometimes  there  Avas  a  lucid  interval,  usually  of  short  duration, 
betAveen  the  tAvo  phases.  Too,  profound  remissions,  especially  in  the  stuporous 
stage,  were  observed.  The  duration  of  the  phases  varied  in  the  same  and 
various  individuals  from  a  fcAV  days  to  months.  They  passed  quite  immedi- 
ately from  one  phase  into  another. 

The  stuporous  phase  AA^as  characterized  by  intercurrent  conditions,  last- 
ing an  hour  or  more,  of  psychomotor  excitement  in  the  form  of  imperative 
ideas,  imperative  actions,  verbigeration,  talkatiA^eness,  with  perA^erse  diction 
and  religious,  pathetic  ideas  and  feelings.  The  maniacal  phases,  in  contrast 
Avith  the  usual  clinical  manifestations  of  furious  mania.  Avere  characterized 
by  ridiculous  pathos  in  manner  and  direction;    inclination  to  A'erbigeration, 


432  SrECIAL  PATTIOLOGY  AND  THERAPY  OF  INSANITY. 

repeated  inipulsively  or  imperatively  without  end;  true  automatic  impulsive 
actions  (turning  in  a  circle,  turning  somersaults,  etc.),  which  arose  upon  the 
foundation  of  degenerative  onanistic  conditions,  all  of  which  were  added  to  the 
maniacal  manifestation  of  genuine  impulsive  movement.  In  the  majority  of 
my  cases  recovery  occurred  out  of  prolonged  stupor  following  a  series  of  alter- 
nating phases,  in  which  the  episodic  states  of  excitement  became  less  and  less 
frequent. 

The  treatment  was,  for  the  most  part,  symptomatic.  Special  attention 
in  all  these  patients,  even  during  the  stuporous  pliase,  should  be  given  to 
onanism,  which  always  has  a  deleterious  effect.  In  some  cases  potassium 
bromide  with  hydrotherapy  seems  to  be  of  use. 

Case  36. — Circular  insauity  iu  the  form  of  alternating  phases 
of  mania  and  stupor. 

S.,  aged  22,  single,  farm  laborer,  is  said  to  come  of  a  healthy  family, 
though  his  father  was  mentally  disturbed  for  some  time  before  his  death,  and 
his  mother  suffered  Avith  frequent  headaches.  The  patient  is  said  to  have  been 
well  until  the  time  of  puberty.  From  that  time  on  he  was  sickly  and  suffered 
with  general  physical  weakness  and  cardiac  palpitation,  and  on  this  account  he 
did  not  perform  his  military  service.  Presrunably  the  cause  was  the  injurious 
effect  of  onanism,  which  the  patient  had  begun  early  and  practiced  excessively. 
He  is  said  to  have  been  rendered  languid  and.  weak  as  a  result  of  it. 

In  1S77,  after  violent  excitement,  he  is  said  to  have  become  suddenly 
stuporous,  and  during  this  period  to  have  been  maniacal.  After  eight  days 
he  was  again  well. 

On  August  25,  1878,  the  patient  became  excited  where  the  A'illagers  were 
dancing,  drank  too  much,  and  was  gi-eatly  affronted  by  the  girl  with  whom  he 
was  in  love.  On  the  26th  he  was  sad,  depressed,  and  after  a  few  hours  he  was 
profoimdly  stuporous  and  could  not  be  roused. 

On  the  28th  he  commenced  to  gesticulate,  verbigerate,  pray,  and  rave. 
He  was  destructive,  danced  about,  was  quite  incoherent,  and  asked  for  copula- 
tion with  the  pastor. 

On  the  30th  he  was  again  stupid,  and  in  this  condition  he  came  to  the 
clinic.  The  patient  was  of  middle  size,  quite  well  nourished,  rhombocephalic. 
He  had  a  narrow  ])alate;  pupils  dilated,  lazy  reaction.  Physically  there  Avas 
nothing  else  remarkable.  The  patient  lay  on  the  floor  inactive,  silent,  stupor- 
ous, and  remained  in  any  position  passively  induced. 

August  31st  there  was  again  a  stiitc  of  excitement.  The  patient  was 
loquacious,  recited  extracts  from  the  Bible  in  high  German,  made  theatric 
gestures  with  his  hands,  and  spoke  with  great  pathos  all  sorts  of  nonsense ; 
for  example,  "Twice  six  is  twelve,  eighteen  is  my  brother,"  etc.  When  an 
attempt  is  made  to  undress  him  he  fights  desperately,  cries  terribly,  grinds  his 
teeth,  and  makes  grimaces.  Left  to  himself  he  stands  with  raised  fists  and 
threatening  mien  and  cries  only  "come  here."  For  an  hour  or  so  at  a  time  he 
is  quiet,  seemingly  lucid,  even  to  the  extent  of  having  insight  into  his  disease. 
Sometimes  there  are  states  of  stiipnr  lasting  several  hours,  willi  theatric  looses 
and  cataleptic  states;  but,  for  the  most  part,  until  September  IGth,  the  pa- 
tient was  in  a  state  of  maniacal  excitement  with  almost  complete  absence  of 
sleep,  great  confusion,  mistaking  those  around  him  for  relatives;    confused. 


PSYCHIC  DEGENERATIONS.  433 

great  loquacity  -with  the  use  of  high  German;    pathetic  affected  diction,  in 
which  there  was  much  talk  of  God,  of  the  Virgin  Mary,  and  of  his  sweetheart. 

On  September  I6th  the  patient  again  became  stuporous  and  remained  so 
until  November  14th.  His  consciousness  is  profoundly  disturbed.  He  pays  no 
attention  to  the  calls  of  Nature  and  at  times  presents  cataleptiform  attitudes 
and  forced  positions.  He  stands  for  hours  at  a  time  in  one  spot,  his  eyes 
directed  into  space  with  a  slight  convergent  squint.  For  the  most  part,  the 
patient  is  dumb;  only  on  one  occasion  did  he  speak  in  a  pathetic,  senseless 
way,  remarking  that  there  was  one  God  and  three  divine  persons.  After  this 
there  Avas  a  short  period  of  verbigeration — "Flea,  fly,"  etc.,.  otherwise  he  was 
dull,  dumb,  and  staring  stupidly.  On  the  13th  he  was  somewhat  freer.  The 
patient  says  that  the  blood  moimted  to  his  head  and  made  him  confused  and 
dizzy.  There  was  frequently  a  rash-like  redness  of  the  face.  It  was  not«d  that 
the  patient,  even  during  his  stuporous  condition,  practiced  onanism,  and  that 
then  the  stupor  always  increased  (potassitun  bromide  and  rubbing;  favorable 
prognosis). 

■  On  November  14th  again  a  state  of  exaltation.  The  patient  became 
sleepless,  prayed,  and  spoke  all  sorts  of  nonsense  in  a  pathetic  way:  "This  is 
the  house  of  misfortune,  I  know  it  is  vile";  occasionally,  too,  verbigeration: 
"Fish,  fishy,"  etc.  Great  confusion,  disconnected  words  and  sentences,  pro- 
found disturbance  of  consciousness.  He  takes  those  around  him  for  the  pope 
and  bishops.  Now  and  then  a  cry  of  fire.  There  was  no  evidence  of  a  pro- 
nounced state  of  feeling.  There  were  joyful  and  painful  moments.  The 
patient  is  in  a  peculiar  state  of  unrest.  He  reduces  the  contents  of  his  straw 
mattress  to  bits  and  turns  for  hours  at  a  time,  as  if  forced,  at  each  half  turn 
stopping  and  saying  some  word;  for  example,  why,  cause,  brother,  Anthony, 
right,  stop,  regiments,  physician,  no,  etc.  After  that,  peculiar  forced  attitudes. 
Temporarily,  on  one  occasion,  forced  asking  of  questions. 

November  29th,  the  patient  became  quiet  and  stuporous.  Just  as  on  the 
former  occasion,  in  the  beginning  of  December  the  stupor  disappeared,  but 
there  was  still  a  certain  forced  condition  of  mien  and  attitude  with  inclination 
to  peculiar  distorted  positions.  Speech  became  free,  but  was  still  affected  and 
in  high  Gennan.  In  the  middle  of  December  the  patient  became  entirely  quiet, 
well  ordered,  and  free  in  movement. 

He  says  that  he  remembers  all  the  events  of  his  sickness.  He  had  been 
quite  confused  in  his  head  and  everything  was  moving  around  him,  and  he  had 
seen  all  sorts  of  forms.  At  times  his  feet  and  hands  were  painfid  and  felt 
dead.  He  had  been  forced  to  turn  around  in  a  circle  because  this  gave  him  a 
lighter  feeling  in  his  head.  On  January  10,  1879,  the  patient  was  discharged 
cured. 

2.  Periodic  Insanity  in  the  Form  of  Morhid  Instincts. 

This  form  of  periodic  disturbance  is  still  but  little  known.  In 
these  cases,  without  doubt,  we  have  to  do  with  instincts  organically 
excited  which  imperatively  demand  satisfaction.  They  form  the 
basis  and  essence  of  the  disease,  and  are  not,  as  in  numerous  cases  of 
simple  or  periodic  alienation,  accidental  and  secondary  symptoms. 

Science  now  recognizes  as  unquestioned  pathologic  manifesta- 
tions the  periodic  recurrence  of  an  impulse  to  drinl?  and  impulsive 


434  SPECIAL  TATHOLOGY  AND  TIIERArY  OF  INSANITY. 

sexual  desire.  The  morbid  and  especially  degenerate  significance  of 
these  states  is  proved  clinicall}''  b}^  their  periodic  retnrn,  accompanied 
by  all  the  clinical  syTiiptoms  of  periodic  insanity.  It  is  to  be  espe- 
cially emphasized  that  the  psychic  ])ersonality  during  the  attack  is 
not  the  same  as  during  the  interval,  and  that  the  morbid  tendency 
of  the  instinct  belongs  only  to  the  psychopathic  personality.  Besides, 
other  degenerate  elements  are  observed,  especially  in  the  tendencies 
of  the  sexual  instincts,  where  the  impulses  are  often  perverse  and 
their  satisfaction  impulsive. 

As  to  periodic  cases  of  psychopathia  sexualis,  which  are  still 
little  known,  it  will  suffice  to  refer  the  reader  to  the  monograph 
by  the  author  of  the  present  work.  On  the  other  hand,  periodic 
dipsomania  seems  to  be  quite  well  known  scientifically,  and  from  a 
practical  standpoint  is  of  enough  importance  to  be  considered  here. 

(aj  Dipsomania,  or  Periodic  Drunkenness. 

Tliere  are  some  individuals  who  are  periodically  attacked  by  a 
morbid  coiidition,  physically  and  mentally,  in  which  the  need  to 
consume  alcohol  is  felt  with  impelling  force:  a  need  to  which  the 
patient,  prevented  temporarily  by  mental  disturbance  from  exercis- 
ing his  ethic  and  intellectual  powers,  can  offer  no  resistance. 

The  dipsomaniac,  in  the  first  place,  differs  from  the  habitual  or  ordinary 
drinker  and  the  chronic  drunkard  in  the  strictly  episodic  character  of  his 
mania  to  drink;  from  the  moral  weakling,  who  offers  no  resistance  to  the 
temptation  to  deliver  himself  up  to  alcoholic  excesses,  which  prevents  him  from 
keeping  liis  week's  or  month's  wages  in  his  pocket,  the  dipsomaniac  differs  in 
that  an  organic  psychic  impelling  force  attacks  and  subjugates  him  without 
regard  to  time,  place,  or  occasion,  and  thus  alone  and  apart,  far  from  the 
circle  of  gay  or  jovial  drinkers,  he  indulges  in  excesses. 

The  dipsomaniac  is  distinguished  from  the  maniac,  who,  owing  to  a  pleas- 
urable sensation  and  a  wildly  gay  humor,  etc.,  gets  drunk,  in  that  i-n  the  former 
the  impulse  is  born  of  a  lively  sensation~^of  displeasure,  and  alcohol  does  not 
produce  in  him  the  physiologic  effect  of  gayety. 

The  dipsomaniac  fiuther  differs  from  the  ordinary  drinker  in  the  fact 
that  in  his  morbid  inebriety  he  is  not  fastidious  in  his  taste;  he  sees  only 
quantity,  and  for  want  of  better  material  becomes  a  prey  to  a  perversion  of 
morbid  taste,  and  under  such  circumstances  may  have  recourse  to  vinegar  or 
even  petroleum. 

The  dipsomaniac  resembles  more  in  his  manner  the  melancholic  who  is 
physiologically  depressed,  and  who  often  seeks  in  wine  or  alcohol  consola- 
tion and  forgetfulness  of  his  soitows  and  misery.  In  fact,  it  is  possible, 
in  the  case  of  the  majority,  to  prove  that  the  dipsomaniac  impulse  occurs  in 
the  course  of  an  acute  attack  of  neurasthenic  dysthymia  with  a  tendency  to 
periodic  recuiTcnce,  and  that  it  is  maintained  by  this  state  of  physical  and 
moral  depressionj    for  alcoliol  is  a  means  of  enjoyment  and  stimulation  for 


PSYCHIC  DEGENERATIONS.  435 

the  nervous  system  (like  morphine,  cocaine,  etc.)  and  of  a  nature  to  render 
more  supportable  the  state  of  mental  and  physical  pain.  Besides,  there  seem 
to  be  some  cases  in  ^^  liicli  the  impulse  to  drink  afflicts  the  individual  in  a 
manner  absolutely  primary  and  as  the  actual  basis  of  the  trouble.  A  more 
minute  analysis  shows  tliat  in  these  cases  there  is  a  state  of  impulsive  raptus 
to  drink,  of  periodic  recurrence,  occurring  in  individuals  of  original  feeble  en- 
dowment {vide  "Moral  Insanity"),  such  as  Mendel  has  recognized;  or  that 
they  are  cases  of  genuine  periodic  dipsomania,  in  which  tlie  clinical  manifesta- 
tion is  that  of  irritable  angry  mania,  if  the  patient  is  kept  from  satisfying 
his  dipsomaniac  impulse. 

Probably  dipsomania  occurs  only  in  tainted  individuals.  Thus 
is  explained  the  fact  that  it  breaks  forth  often  during  the  physiologic 
phases  of  menstruation,  pregnancy,  and  the  climacteric,  which  seem 
to  intensify  predisposition  to  this  disease ;  and,  too,  very  frequently 
the  presence  of  constitutional  neuroses  (n'eu.rasthenia,  hysteria,  epi- 
lepsy) is  observed.  The  primary  exciting  cause  is  usually  some  lively 
moral  emotion,  or  physical  or  intellectual  overwork.  An  acute  state 
of  neurasthenic  dysthymia  thu.s  induced,  or  an  exacerbation  of  a 
neurosis  that  has  existed  for  a  long  time,  is  immediately  added  and 
represents  the  prodromal  stage,  which  may  last  some  hours  or  even 
several  days. 

The  patient  becomes  sleepless,  congested,  complains  of  pressure 
in  the  head,  increasing  mental  inhibition  and  discomfort  and  des- 
perate ennui,  general  fatigue,  nervous  excitement  and  restlessness, 
apprehensive  oppression,  hot  and  cold  feelings,  and  paralgic  sensa- 
tions. Then  an  instinctive,  imperative,  impulsive  desire  for  alcohol 
awakes,  which  finally,  after  a  fearful  struggle  that  may  go  even  to 
the  extent  of  tcedium  vitce,  conquers.  The  very  first  glasses  bring 
(temporary)  relief,  in  which  alcohol  produces  sleep  and  indifference, 
and  acts  as  a  stimulant,  without,  however,  giving  the  patient  real 
pleasure. 

The  neurasthenic  and  dysthjinic  patient  is  forced  to  have  re- 
course to  the  bottle  again  and  again,  just  as  the  liabitue  of  morphine 
in  a  certain  stage  is  forced  to  take  injection  after  injection.  To  these 
signs  of  the  disease  those  of  alcoholic  intoxication  are  gradually 
added,  which,  however,  like  the  altered  toxic  effect  of  mori^hine  in 
certain  psychic  exceptional  states,  are  slighter  and  occur  later,  as  a 
rule,  than  under  normal  circumstances. 

This  continues  some  days,  sometimes  even  weeks;  but  during 
this  continuance  there  may  be  numerous  attacks  grouped  together 
or  separated  by  remissions  or  intermissions.  Finally,  and  usually 
with  sudden  subsidence,  the  attack  ends.  The  patient  becomes  quiet, 
exhausted,  and  feels  no  desire  for  spirits.    He  begins  to  sleep  again 


436  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

and  passes  through  a  stage  of  mental  torpor,  with  more  or  less  pro- 
iioiincod  mnnifostations  of  acute  alcoholism,  into  his  previous  con- 
dition ;  l)ui  of  Ion  for  days  there  is  restless,  nnrefreshing  sleep,  men- 
tal prostration,  and  general  discomfort,  and  the  patients  are,  even 
in  the  absence  of  these  troubles,  tortured  with  remorse. 

Where  the  attacks  are  protracted  or  frequent,  tlie  paroxysm  may 
be  followed  by  symptoms  of  delirium  li'duens,  and  syinpionis  of 
chronic  alcoholisin  may  develop. 

The  attacks  of  dipsoninuia  may  bo  sojiaralod  l)y  wi'oks  or  months, 
sometimes  by  a  year.  The  ]>rognosis  is,  in  general,  unfavorable. 
Only  confinement  in  an  asylum  during  sonio  yoai's,  in  coniicclion  Avith 
tonic  treatment  {romp,  neurasthenia)  and  (lio  onipii-ic  use  of  drugs 
which  may  abort  (injootions  of  iin)rpliino)  the  attaok  or  calm  it 
(opium,  joaraldehyde,  amyl  hydrate)  when  developed,  holds  out  any 
hope  for  these  patients. 

Case  3T. — Dipsomania. 

K.,  mercliant,  aged  59,  a  self-made  man  of  great  capabilities  and  great 
industry,  consulted  me  in  June,"  188G,  on  account  of  dipsomania.  His  father 
Avas  nervous  and  easily  excitable.  The  patient  said  that  he  himself  was 
nervous,  excitable,  emotional,  and  always  melancholy,  sentimental,  easily 
irritated  when  things  went  against  his  Avish,  and  that  it  was  only  with  diffi- 
culty that  lie  regained  his  cMiuilil)rinm,  losing  sloop  dining  a  long  period.  A 
relative  stated  that  llui  ]i;ilioiil  was  uoxcr  really  in  a  state  of  emotional 
equilibrium,  always  either  dei)res.sod  or  exalted.  The  patient  had  many  cares 
and  juuch  excitement  in  his  family  and  his  enormous  business. 

In  1873,  as  a  result  of  financial  anxieties,  he  became  acutely  neurasthenic, 
dysthymic,  sleepless,  lost  courage,  and  sank  in  despair.  In  this  condition, 
contrary  to  his  habit,  he  began  to  drink.  After  eight  days  he  was  again  in 
his  usual  condition.  Thereafter  the  patient  was  relatively  well,  very  active, 
and  well  ordered  in  his  life.  Four  and  one-half  years  ago,  following  violent 
mental  excitement,  a  dipsomaniaco-raaniacal  condition  came  on,  and  had  re- 
curred since  at  intervals  of  four  or  five  months.  Prodromal  symptoms,  in  the 
sense  of  irritability  of  the  nervous  system,  could  be  found,  dating  back  two 
years  before  this  attack,  for  the  patient  was  more  quickly  fatigued  mentally 
and  physically,  slept  badly,  was  tired  in  the  morning,  felt  languid,  showed 
increasing  emotionality  and  irritability,  and  reacted  with  unusual  severity  to 
unpleasant  things.  For  these  neurasthenic  symptoms  now  and  then  the  pa- 
tient took  brandy,  with  some  good  effect.    Occasionally  he  took  can  de  Cologne. 

The  prodromes  of  attacks  last  even  ten  days,  and  consist  of  manifesta- 
tions of  increasing  neurasthenia,  as  well  as  dysthymia  and  predominating 
symptoms  of  psychic  inhibition. 

There  are  great  fatigue,  mental  and  physical  depression,  lack  of  interest 
in  everything,  even  to  the  extent  of  apathy  and  abulia,  with  great  desire  for 
sleep.  The  patient  characterizes  his  condition  at  this  period  as  that  of  the 
moral  and  physical  pain  of  a  debauch:  he  is  extremel,y  weak,  morose,  and  has 
a  repugnance  for  the  most  important  social  relations;  desperately  bored,  and 
has  no  interest  in  anytliing. 


PSYCHIC  DEGENERATIONS.  437 

In  order  to  free  himself  of  this  unbearable  condition  he  resorts  to  spirits, 
and  that  the  more  willingly  because  they  bring  him  sleep.  In  the  absence  of 
wine  and  liquors  he  had  resorted  to  ordinary  spirits,  even  vinegar  and  petro- 
leum. He  never  drinks  from  thirst,  but  as  a  result  of  the  necessity  of  over- 
coming his  terrible  condition.  He  had  never  had  any  pleasure  from  drinking. 
His  tolerance  for  alcoholics  seems  remarkable  to  him.  Thus,  at  the  height 
of  an  attack,  he  would  drink  as  many  as  twenty-five  glasses  of  bi-andy  ami 
much  wine  in  a  single  day,  witliout  becoming  intoxicated.  His  acquaintances 
report  that  when  the  patient  is  kept  from  drink  lie  becomes  angrily  excited, 
goes  out  of  the  house  in  najlUjC  in  order  to  satisfy  his  impulse  in  the  lowest 
drinking  places.  Left  to  himself,  the  patient  passes  the  gi-eater  part  of  the 
day  in  bed,  abundantly  supplied  with  brandy  and  wines.  He  avoids  all  mental 
activity,  reading  at  most  nothing  more  than  children's  stories,  and  will  see 
none  of  his  familjr.  The  patient  remains  in  this  condition  sometimes  as  long 
as  four  weeks;  yet  there  are  intermissions  of  from  two  to  ten  days;  so  that 
protracted  attacks  are  really  a  series  of  repeated  attacks.  At  the  height  of 
the  attack  the  patient  is  always  sleepless.  During  this  time  Uhldo  sexuaJis; 
which  is  otherwise  normal,  is  absolutely  wanting. 

The  termination  of  the  attack  occurs  quickly,  Avith  disappearance  of  the 
dysthymic,  abulic,  and  neurasthenic  troubles,  and  with  the  return  of  satisfac- 
tory and  refreshing  sleep,  but  the  sleep  is  at  first  troubled  with  frightful 
dreams.  No  symptoms  of  alcoholism.  During  the  interval,  with  the  exception 
of  his  habitual  nervousness  and  his  unstable  emotional  state,  which  alternates 
constantly  between  extremes,  he  is  well  and  has  no  desire  for  alcohol. 

The  physical  examination  shows  nothing  abnormal  in  a  man  pow-erfuUy 
built.  The  neuropathic  expression  of  the  eyes  is  noteworthy.  The  treatment 
in  the  beginning  (hydrotherapy,  sea-bathing,  mountain  climate,  etc.)  was 
directed  to  toning  up  the  nei-vous  system.  The  attacks  returned  typically, 
but  rmder  treatment  with  opium  (up  to  0.15  gram  of  extract!  opii  aquosae) 
they  ran  a  mild  course,  so  that  tw^o  glasses  of  red  wine  and  one  bottle  of  beer 
a  day  sufficed  to  satisfy  his  desire  for  alcohol.  Paraldehyde  had  a  satisfactory 
hypnotic  effect. 

(I)J  Periodic  Recurring  AMormal  Sexual  Imimlse. 

Aside  from  cases  of  occasional  and  nncontrolIaMe  sexual  excite- 
ment occurring  in  connection  with  states  of  periodic  maniacal  excite- 
ment that  are  heterosexual,  but  sometimes  also  homosexual  (cases 
of  Servaes,  Gock),  and  forming  pictures  of  temporary  sat3rriasis  or 
nymphomania,  there  are  other  cases  in  which,  without  simultaneous 
general  mental  disturbance,  an  abnormal  and  often  perverse  sexuality 
forms  the  nucleus  of  the  entire  mental  disturbance,  as  in  dipsomania, 
and  occurs  only  in  the  form  of  periodic  attacks,  while  in  the  intervals 
the  sexual  impulse  is  neither  abnormal  nor  perverse.  The  cases  of 
Anjel  and  Tarnowsky  were  in  some  instances  examples  of  paedophilia, 
erotica,  in  others  of  pederasty. 

In  the  paroxysm  which  came  on  suddenly  and  as  suddenly  passed 
off,  lasting  usually  only  a  day,  there  was  a  condition  of  mental  ex- 


438  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

citement  with  sleeplessness,  with  painful  ideas  and  impulses  to  act 
in  the  sense  of  the  perverse  sexual  inclination. 

At  the  same  time  there  was  anxiety,  with  constantly  increasing 
impulse  to  the  sexual  act  wliich  was  otherwise  held  in  horror,  but 
during  the  attack  was  desired  because  it  would  bring  an  end  to  the 
condition. 

A  ])eculiar  phenomenon  belonging  here  is  observed  in  cases  of 
paroxysmal  patluilogic  love  of  married  women  for  other  men,  of  such 
power  that  all  thought  of  shame,  morals,  and  honor  are  overcome, 
and  the  love  for  another  is  shamelessly  expressed,  even  to  the 
husband. 

In  the  beginning  of  the  trouble  the  efforts  that  are  made  to 
overcome  this  illegitinuite  inclination  induce  violent  attacks  of  dis- 
tress. 

During  the  existence  of  the  pathologic  condition  thei-e  is  com- 
plete indifference  toward  husband  and  children,  complete  lack  of 
insight  into  the  significance  and  results  of  the  scandalous  conduct 
that  takes  no  account  of  marital  worthiness  and  family  honor. 

In  contrast  with  the  non-psychopathic,  though  alDuormally  libid- 
inous, misalliance,  it  is  remarkable  in  these  cases  that  the  sexual 
error  is  only  an  episode  in  the  life  of  an  honest  wife,  who,  once  re- 
covered, expresses  the  most  profound  sorrow  at  what  has  taken  place. 

It  is  also  remarkable  that  the  abnormal  episode  is  not  regarded 
so  much  a  sin  as  an  unavoidable  misfortune  arising  out  of  an  abnor- 
mal mental  condition. 

Such  paroxysms  may  last  even  several  months. 

II    Periodic  Insanity  of  Sympathetic  Origin-. 

Here  we  have  to  do  with  insane  conditions  caused  by  peripheral 
irritation  periodically  affecting  the  brain.  That  these  irritants  have 
this  effect  is  to  be  explained  by  the  abnormal  constitution  of  that 
organ,  which,  Avithout  exception,  in  such  cases,  is  demonstrable  and 
usually  found  to  be  a  result  of  hereditary  taint.  Most  frequently 
Buch  irritation  has  its  origin  in  the  genital  nervous  system,  and  it  is 
especially  the  process  of  menstruation,  as  well  as  diseases  of  the 
uterus,  according  to  Kirn's  observations,  that  occasion  such  parox- 
ysms of  frecjuently  repeated  insanity  with  typically  congruent  symp- 
toms and  course. 

Menstrual  Insanity. 

The  purest  form  of  sympathetic  insanity  is  menstrual:  i.e., 
mental  disturbance  associated  with  the  period  or  the  process  of  men- 


PSYCHIC  DEGENERATIONS.  439 

struation,  which  is  manifested  clinically  in  the  form  of  a  psychosis 
like  mania,  less  frequently  melancholia,  or  as  delii'ium.  In  all  cases 
of  this  menstrual  insanity  we  have  to  deal  with  an  originally  ab- 
normal excitable  brain,  which,  before  the  attack  as  well  as  during 
the  intervals,  reacts  pathologically.  The  majority  of  individuals 
afflicted  with  this  disease  wore  hereditarily  tainted,  and  all  presented 
a  neuropathic  constitution,  were  originally  weak-minded,  or  afflicted 
with  functional  and  some  with  somatic  signs  of  degeneration. 

The  neuropathic  constitution  was  early  manifested  and  very 
evident  after  the  time  of  puberty.  In  the  majority  of  cases,  in  health 
the -menses  were  accompanied  with  nervous  disturbances,  mental 
excitement,  and  depression.  In  many  cases  the  sexual  psychosis  was 
preceded  by  neuroses  (hysteria)  or  attacks  of  non-periodic  insanity. 

In  numerous  cases,  upon  the  basis  of  such  a  predisposition,  slight 
external  causes  —  emotions,  alcoholic  excesses,  physical  diseases  — 
were  sufficient  at  the  time  of  the  next  menstruation  to  cause  the 
outbreak  of  the  disease.  Where  the  disease  was  once  developed, 
merely  the  process  of  menstruation,  with  its  physiologic  influence  to 
increase  the  excitability  of  the  central  nervous  system,  sufficed  to 
bring  on  the  paroxysm,  since,  analogous  to  the  brain  change  in  epi- 
leps}^,  a  permanent  functional  alteration  had  developed  in  the  brain. 

It  is  worthy  of  note  that  in  developed  cases,  even  when  the  men- 
strual discharge  is  wanting,  at  the  time  of  the  periodic  recurrence 
of  ovulation  the  attack  may  occur. 

The  first  outbreak  of  the  disease  may  take  place  in  any  men- 
strual period  of  the  sexual  life;  in  general^  the  earlier,  the  greater 
the  predisposition.  Diseases  of  the  genitals  and  irregularity  of  the 
menses  are  frequently  found;  still,  the  disease  occurs  in  cases  where 
no  functional  or  anatomic  abnormality  of  the  sexual  apparatus  exists. 

The  pathogenesis  must  be  sovight  in  vasomotor  disturbances  which  arise 
in  the  brain  reflexly  from  the  ovarian  nerA^es  excited  during  the  process  of 
oAailation.  The  fact  that  the  physiologic  process  of  menstruation  causes  such 
pronounced  reflex  efl'ects  is  to  be  explained  by  the  degenerate  brain  of  the 
individuals  prone  to  develop  menstrual  insanity.  In  accordance  with  the  de- 
gree of  this  taint  there  are  menstrual  nerA^ous  symptoms  which  vary  from 
simple  migraine  to  attacks  of  insanity. 

It  is  to  be  presumed  from  physiologic  experiments  (Schlesinger)  that  the 
centers  of  the  A-ascular  and  uterine  nerA^es  lie  close  together  and  manifest  a 
similar  reaction  to  certain  stimuli. 

As  prodromes  of  menstrual  insanit}'-,  which  sometimes  precede 
it  sevesal  days,  are  to  be  mentioned  sleeplessness  and  great  emotional 
irritability.     Not  infrequently  the  sjmiptom-complex  begins  with  a 


440  SPECTAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

state  of  congestion,  headache,  vertigo,  and  a  feeling  of  oppression  in 
the  epigastrinm. 

The  insanity  occurs  hefore,  sometimes  alter,  and  sometimes  dnr- 
ing  the  process  of  menstruation.  The  relation  in  time  to  mcnstrna- 
tion  may  he  altered  during  the  course  of  the  disease  without  any 
essential  change  in  the  disease-picture.  In  cases  of  premenstrnal  in- 
sanity frequently  the  attack  ceases  with  the  beginning  of  the  menses. 

Menstrual  insanity  resembles  other  forms  of  periodic  insanity 
in  this:  its  outbreak  and  end  are  sudden,  and  the  single  attacks  are 
alike,  even  in  their  smallest  detail;  the  personality  during  the  attack 
is  mimically  absolutely  different  from  the  personality  of  the  interval, 
and  during  the  intervals  numerous  psychic  and  nervous  symptoms  are 
present. 

To  the  disease-picture  special  features  are  lent  by  the  sudden  out- 
break and  ending  of  the  attack,  by  the  usually  very  marked  cerebral 
congestion,  the  profound  disturbance  of  consciousness  with  the  re- 
sulting summary  memory,  by  the  great  nmnber  of  hallucinations,  and 
the  frequent  termination  through  a  stage  of  stupor.  The  disease- 
picture  nu^y  be  maniacal,  especially  in  the  form  of  angry  mania, 
melancholic,  or  one  of  hallucinatory  delirium.  The  never-failing 
s3-mptoms  of  the  interval  referable  to  the  nervous  system  are  partly 
the  expression  of  the  neuropathic  constitution,  partly  symptoms  of 
the  accompanying  hysteria  or  other  nervous  symptom-complexes.  It 
is  often  difficult  to  distinguish  the  results  of  one  attack  (fatigue, 
stupor)  from  the  prodromes  of  an  attack  to  follow. 

There  are  cases  in  which  the  attack  recurs  t3'pically  with  every 
menstrual  period.  In  tune,  under  such  circumstances,  the  attacks 
become  more  intense  and  severe,  and  at  the  same  time  more  pro- 
longed; then  secondary  states  of  mental  weakness  arise  (general 
confusion,  dementia).  The  excitement  may  then  become  permanent, 
one  attack  passing  over  into  another. 

Spontaneous  temporary  absence  of  attacks  occurs,  sometimes 
due  to  severe  acute  diseases  (typhoid),  or  to  amenorrhea  accompanied 
by  cessation  of  ovulation,  when  the  exciting  cause  of  the  recurring 
attacks  is  removed;  but  this  also  is  aided  by  the  influence  of  care  in 
a  hospital. 

The  prognosis,  when  the  disease  is  not  of  long  standing  and  the 
attacks  do  not  recur  regularly,  is  not  unfavorable,  even  though  the 
predisposition  cannot  be  overcome.  From  a  therapeutic  standpoint 
the  causal  indication  demands  treatment  of  the  neuropathic  consti- 
tution: i.e.,  treatment  of  the  increased  excitability  of  the  brain 
psychically,  avoidance  of  sexual  excitement,  strengthening  the  con- 


PSYCHIC  DEGENERATIONS.  44 1 

stitiition  (liyclrotliorap3^),  treatment  of  anemia  (iron),  and  troatmont 
of  any  uterine  diseases  or  anomalies  of  nKinstrnaiion  that  may  Le 
present  (gynecologic  treatment). 

Prophylaxis  of  the  single  attack  demands  exact  attention  to  the 
menstrual  period,  determination  whether  the  attack  is  premenstrual 
or  postmen strual,  and  an  attempt  artificially  to  diminish  the  in- 
creased excitability  at  the  dangerous  period  by  the  use  of  bromides 
in  doses  not  under  G  grams  a  day,  and  under  some  circumstances 
increased  to  10  grams.  During  the  intermenstrual  period  llie  treat- 
ment should  be  interrupted  in  order  to  avoid  poisoning.  Where 
there  is  amenorrhea  and  irregular  menses,  bromides  must  be  given 
continually  in  smaller  doses  (from  4  to  6  grams).  This  is  quickly 
increased  to  8  grams  as  soon  as  the  menses  appear.  Atropine,  rec- 
ommended by  Weiss,  as  well  as  ergotine,  recommended  by  Schlangen- 
hausen,  in  cases  under  my  observation  have  had  neither  a  preventive 
nor  ameliorating  effect.  Symptomatic  indications  demand  during  the 
attack  rest  in  bed  and  isolation.  Bromides  have  no  abortive  effect 
here,  but  they  ameliorate  the  attack.  Where  there  is  violent  con- 
gestion, ice-bags  and  baths  are  useful.  In  some  chronic  eases  injec- 
tions of  morphine  have  an  effect  to  ameliorate  and  shorten  attacks. 
They  have  no  prophjdactic  value. 

Case  38.- — Periodic  menstrual  mania. 

Mrs.  A.  S.,  aged  23,  of  very  tainted  family.  As  a  child  was  scrofulous 
and  developed  with  unusiial  rapidity.  She  was  talented,  alwaj^s  eccentric,  and 
given  to  enthusiasm,  and  was  nervous  and  emotionally  very  excitable.  •  Menses 
at  16,  thereafter  regular,  but  frequently  profuse.  At  18  hysteric  manifesta- 
tions, with  clonic  and  tonic  cramps.  Later  great  nervousness  and  frequent 
attacks  of  fainting. 

In  the  summer  of  1874  the  patient  fell  in  love  with  a  gentleman  who 
knew  nothing  of  her  preference.  She  became  very  much  exalted,  and  her  rela- 
tives finally  destroyed  her  illusion.  As  a  result  of  this  she  became  hypo- 
chondriac and  melancholic,  abulic,  and  thought  that  she  had  heart  disease  and 
was  soon  to  die. 

October  20th,  menses  for  some  da3^s ;  thereafter  exalted,  gay,  restless, 
sleeplessness.  October  30th,  within  a  few  horu's  a  state  of  intense  mania  de- 
veloped. Joyful  affect  going  on  to  ecstasy.  Great  motor  excitement,  flight  of 
ideas,  confusion,  alliteration  and  rhyming,  erotic  manifestations,  and  delirium. 
She  is  pregnant  and  constantly  talks  about  heart,  love's  bond,  cavalrymen,  her 
divine  Theodore,  to  whom  she  has  given  her  heart  and  hand.  Those  around 
her  are  struck  and  kicked,  out  of  pure  pleasure  in  movement.  There  is,  at  the 
same  time,  salivation,  but  no  signs  of  cerebral  congestion.  Pulse,,  small,  80; 
no  anemia;  no  motor  or  sensory  functional  disturbances.  Constipation.  Pro- 
longed baths.     Potassium  bromide,  4  grams. 

November  6th,  sudden  transformation  of  the  mania  into  quietness  and 
lucidity,  with  insight  into  the  disease.    Patient  is  very  emotional  and  sensitive 


442  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

to  sounds  and  light,  much  fatigued,  and  in  need  of  rest  in  bed.  The  patient 
has  only  a  summary  memory  for  the  events  of  her  disease.  Prolonged  baths 
at  night  ameliorate  headache,  impulse  to  think,  and  sleeplessness.  November 
12th,  menses  profuse  until  November  18th.  November  16th,  potassium  bro- 
mide was  suspended.  November  25th,  without  any  cause,  after  having  head- 
ache several  hours,  the  patient  became  maniacal.  The  attack  came  on  sud- 
denly, reached  its  acme  within  a  few  hours,  and  went  through  a  course  exactly 
like  tlie  first:  continued  expansive  affect,  gay,  erotic,  great  ideational  activitj% 
iiifoherenec,  with  the  same  llioughls  and  errors  iji  tlic  recognition  of  persons  as 
(in  the  first  occasion.  December  Gth,  sudden  cessation  of  mania,  with  the  same 
sMnptoms  during  the  interval  as  after  the  first  attack.  From  November  25th 
luitil  December  Gth  the  patient  was  given  daily  8  grams  of  potassium  bromide 
— it  was  used  symptomatically,  merely  during  the  height  of  the  paroxysm, 
and  showed  itself,  for  tliis  purpose,  to  be  witliout  effect.  From  November  lllh 
to  16th,  menses.  On  December  20th,  after  a  sleepless  night  and  some  head- 
aclie,  another  attack  of  mania  lasting  until  the  28th,  having  exactly  the  same 
features  as  the  former  attacks.  Since  now  the  periodic  menstrual  significance 
of  the  case  was  beyond  all  doubt,  from  December  20th  a  dose  of  8  grams  of 
potassium  bromide  was  given  daily  in  the  hope  of  attaining  a  preventive  eftect. 
January  7th,  depressing  thoughts,  anxious  dreams,  but  no  mania.  From 
January  13th  on  12  grams  of  potassium  bromide,  and  on  the  15th  of  January 
headache  and  intercostal  neuralgia.  The  critical  period  was  passed  witliout  an 
attack,  but  from  the  20th  of  January  on  there  were  signs  of  commencing 
intoxication  with  potassium  bromide:  great  sleepiness;  muscular  weakness; 
slow,  small  pulse;  weak  heart-sounds.  February  5tli,  menses.  The  symptoms 
of  intoxication  increase.  Stupor,  general  paresis  with  intact  sensibility  and 
reflex  excitability.  Vomiting  of  thick  slime,  anesthesia  of  the  throat,  poor 
radial  pulse,  impossibility  to  eat,  to  sit  up.  With  the  continued  use  of  12 
grams  of  potassium  bromide  the  critical  period  is  passed.  After  February  20th 
only  4  grams  of  bromide  were  given.  Reeling,  staggering  gait,  total  dementia, 
weak  lieart-sounds,  thready  pulse,  114.  After  February  25th,  potassiiun  bro- 
mide is  discontinued.  From  February  27th  disappearance  of  stupor,  muscular 
and  heart  weakness.  March  10th,  all  signs  of  bromide  intoxication  completely 
absent;  menses;  2  grams  of  potassium  bromide;  on  the  13th,  6  grams;  on 
the  15th,  8  grams;  on  the  17th,  6  grams;  and  the  21st,  3  grams;  no  altera- 
tion of  the  general  condition.  March  22d,  suspension  of  potassium  bromide, 
which  on  this  occasion  left  behind  no  traces  of  intoxication.  Aside  from  slight 
nei'vous  troubles,  quite  well  in  the  interval.  April  4th,  4  grams  of  potassium 
bromide;  menses  on  April  6th;  on  April  9th,  6  gi'ams.  On  April  11th,  menses 
ended.  On  April  13th,  4  grams,  and  on  the  16th  of  April  suspension  of  potas- 
sium bromide.  Aside  from  some  headache,  on  this  occasion  there  was  nothing 
abnormal  to  note.  Thereafter  frequently  globus  and  intercostal  neuralgia. 
On  May  3d,  menses;  4  grams  of  potassium  bromide,  daily  increased  by  1 
gram.  On  May  8th,  menses  finished.  On  May.  10th,  6  grams;  May  14th,  4 
grams;  May  18th,  suspension  of  the  bromide,  feeling  perfectly'  well.  On  May 
26th,  menses  a  few  days  too  early;  4  grams  of  potassium  bromide  the  follow- 
ing days.  Globus  and  weeping,  and  on  May  29th,  6  grams,  and  on  the  30th  of 
May  menses  finished.  June  1st,  suspension  of  the  bromide.  In  the  beginning 
of  June  discharged  recovered.  Thereafter  patient  was  well  and  in  excellent 
physical  health,  the  hysteric  troubles  disappearing  entirely.     No  more  mental 


PSYCHIC  DEGENERATIONS.  443 

disturbance  was  observed.  At  the  time  of  the  menses,  which  occurred  regu- 
larly, as  a  i^recaution  potassium  bromide  was  used  as  before.  After  January, 
1876,  with  the  suspension  of  the  drug,  there  were  no  other  psychopatliic 
symptoms  connected  with  the  menses. 


PART  THIRD. 

Mental  Disease  Developing  out  of  Constitutional 

Neuroses. 


In  the  general  description  of  abnormal  jiredisposition  (comp. 
page  361)  attention  was  called  to  the  frequency  Avith  wliich,  in  indi- 
viduals afflicted  with  such  predisposition,  neuroses  occur,  the  eil'ects 
of  which  can  be  traced  like  a  red  thread  tlirough  the  whole  of  the 
patient's  life. 

This  is  especially  true  of  states  of  neurasthenia,  hysteria,  and 
hypochondria.  This  is  not  an  accidental  association,  but  one  of  the 
clinical  manifestations  of  predisposition  in  general.  The  neurosis 
is  an  integral  factor  in  the  predisposition  and  development  of  the 
psycho-physical  personality, — a  burden,  in  the  true  sense  of  that 
word, — which  the  unfortunate  must  bear  with  him  through  the  great- 
est part  of  his  life,  which  only  seldom  and  temporarily  he  can  unload, 
and  which  very  frequently  causes  mental  invalidism. 

The  neurosis  has  a  profound  constitutional  significance  clearly 
based  on  the  abnormalities  of  the  constitution  and  development  of 
the  central  nervous  system,  and  stands  in  clear  and  decisive  contrast, 
from  a  prognostic  standpoint,  with  the  same  neurosis  manifested  in 
a  benignant  and  episodic  way  when  a  well-constituted  nervous  system 
becomes  afflicted  with  it.  'We  have  to  deal  with  quite  analogous  etio- 
logic,  clinical,  and  prognostic  differences,  just  as  in  the  case  of  the 
psychoses  when  they  develop  upon  a  predisposed  or  an  untainted 
foundation.  We  have  but  to  appreciate  the  difference  between  a 
constitutional  folie  raisonnante  manifesting  itself  in  mild  melan- 
cholia and  a  mild  melancholia  in  the  sense  of  a  psychoneurosis.  Siini- 
larly  there  is  the  same  difference  between  a  postpuerperal  or  a 
postfebrile  acute  or  subacute  neurasthenia  and  a  constitutional  neu- 
rasthenia, even  though  benign  and  mild,  manifested  in  early  years 
and  developed  with  the  process  of  puberty,  continued  throughout  life 
like  a  fatality  in  a  central  nervous  system  morbidly  predisposed,  and 
though  from  time  to  time  latent,  always  reappearing  as  a  result  of 
slight  accidents.     Such  a  personality  during  all  his  life  is  menaced 


MENTAL  DISEASE  FKOM  CONSTITUTIONAL  NEUROSES.        44  5 

with  mental  disease,  which  often  must  be  interpreted  as  tlie  terminal 
stage  of  a  morbid  state,  tending  always  to  greater  and  greater  devel- 
opment, and  becoming  more  and  more  extensive  and  degenerate. 


CHAPTER  I. 
Insanity  on  a  Neurasthenic  Foundation. 

The  Asthenic  Neueopsychosis. 

The  name  neurasthenia,  or  nervous  weakness,  covers  a  state  of 
the  general  nervous  system  which  is  appearing  more  and  more  fre- 
quently under  the  circumstances  attending  our  modern  civilization. 
Its  fundamental  symptoms  clinically  are  the  abnormal  impression- 
ability and  extreme  exhaustibility  of  the  nervous  functions,  which 
probably  are  the  expression  of  disturbed  nutrition  of  the  central 
nervous  system  that  brings  about  insufQcient  storage  of  force  and 
but  slow  restoration  of  energy  that  has  been  expended. 

Since  asthenic  persons  that  present  this  characteristic  in  their 
tissue-changes  and  their  functional  activities  eat  and  digest  well,  and 
may  even  look  fresh  and  well  nourished,  the  assumed  disturbance  of 
nutrition  in  nerve-centers  must  be  of  a  minute  kind,  perhaps  a 
trophic  anomaly  of  the  ganglion-cells,  owing  to  which  they  can  create 
only  inferior  chemic  products  out  of  the  nutrient  material  afforded 
them.  The  central  nervous  system  is  thus  functionally  injured.  This 
defect  shows  itself  essentially  in  that  the  inhibitory  activity  of  higher 
centers  is  insufficient.  This  explains  the  abnormal  facility  with 
which  irradiation  and  reflex  effects  occur,  the  most  important 
sources  of  which  are  the  genito-urinary  tract,  the  vegetative  func- 
tions, and  the  brain. 

These  reflex  influences  are  especially  clear  and  active  in  the 
vasomotor  and  cardiac  nervous  territories,  as  a  result  of  which  blood- 
pressure  and  tension  are  subject  to  constant  variations.  It  is  still 
a  matter  for  discussion  whether  neurasthenia  is  a  distinct  neurosis 
or  a  peculiar  pathologic  manner  of  reaction  of  the  central  nervous 
system.  Every  observer  of  experience  will  admit  that  neurasthenia 
presents  a  grouping  of  clinical  symptoms  that  is  peculiar,  and  is  a 
disease-picture  unique  and  always  easily  recognized,  notwithstanding 
the  great  variety  of  symptoms  it  presents,  and  which  occur  in  other 
neuroses  as  if  they  had  been  borrowed  from  neurasthenia;  that  there 
are  cases  presenting  transitional  forms  to  other  neuroses;  that  cases 
may  be  complicated  even  with  hypochondria  and  hysteria. 


446  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Neurasthenia  is  a  general  neurosis — i.e.^  one  affecting  the  whole 
nervous  system;  and,  since  mental  disturbances  play  an  important 
role,  it  may  be  called  a  neuropsychosis.  Occurring  in  a  benign  form 
in  persons  without  predisposition,  and  due  to  a  temporary  and  re- 
movable cause,  it  has  a  subacute  course,  and,  at  most,  after  a  few 
months  it  ends  in  recovery.  The  constitutional  form,  with  which  we 
are  here  concerned,  is  a  chronic  neurosis,  continuing  through  years 
or  decades  with  a  course  presenting  remissions  and  exacerbations, 
and  ending  not  infrequently  in  invalidism  or  mental  disease. 

Earely  its  beginning  is  sudden,  and  under  such  circumstances 
it  is  always  based  upon  marked  predisposition  and  a  violent,  shock- 
like exciting  cause. 

As  a  rule,  this  disease  develops  gradually,  with  manifestations 
of  irritation  and  exhaustion  of  the  nervous  system,  which  at  first 
are  overcome  by  rest  and  sleep,  but  which  finally  become  permanent, 
because  the  central  organ  is  no  longer  able  to  establish  an  equilib- 
rium between  production  and  expenditure  of  nervous  force.  The 
symptoms  of  exhaustion  are  disturbances  of  general  feeling  in  the 
sense  of  general  fatigue,  lassitude,  painful  feelings  of  mental  iuhibi- 
tion  and  ditficulty  of  mental  activity,  need  of  sleep,  food,  and  drink, 
and  even  of  stimuli. 

Very  early  the  mind  suffers  and  the  patient  is  troubled  with  an 
anxious  feeling  of  threatening  serious  disease.  Very  soon,  to  these 
symptoms  of  exhaustion  those  of  excitation  are  added  —  emotional 
irritability,  erethism  of  the  cortex — as  a  result  of  which  the  imagi- 
nation becomes  abnormally  intense,  and  certain  thoughts,  especially 
those  of  a  painful  character,  are  constantly  present,  and  even  at 
night  do  not  allow  the  exhausted  brain  to  rest,  continuing  eveu  in 
sleep.  Sleep  thus  is  often  broken  and  seems  to  be  a  half-Avaking 
state  of  troubled  dreams,  that  brings  no  refreshment.  Other  early 
symptoms  are  vasomotor,  or  congestions  of  various  regions  (dullness 
in  the  head,  congestion  of  the  brain,  cardiac  ])alpitation,  feelings  of 
oppression,  etc.;  anemia,  and  vascular  spasm,  which  may  cause  local 
asphyxia,  cold  feelings,  etc.). 

The  most  important  general  symptom  in  the  course  is  the  feeling 
of  broken  physical  and  mental  power,  and  depression  as  a  conscious 
reaction,  Avith  lack  of  hope  in  the  future,  that  may  go  to  the  extent 
of  desperate  nosophobia.  AVith  the  continuance  of  the  fundamental 
disease  the  groups  of  s3Tnptoms  and  their  local  manifestations  may 
change.  Accidental  injurious  influences  are  frequently  sufficient  to 
cause  this;  for  example,  an  error  of  diet  may  cause  temporary  pre- 
dominating gastric  troubles ;  a  moral  shock,  predominating  affection 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        447 

of  the  cardiac  nerves;   or  relative  mental  overexertion  may  induce 
predominating  cerebral  symptoms. 

A  description  in  detail  of  the  elementary  symptoms  of  the  disturbed 
nervous  functions  as  they  occur  in  nemasthenia  must,  in  the  first  place,  take 
into  consideration  the  mental  disturbances. 

Mental  disturbances  are  constant,  and  their  character  is  that  of  depres- 
sion caused  by  the  feeling  of  severe  physical  illness;  and  on  the  formal  side 
they  are  distinguished  by  the  facilitation  of  emotional  activities,  which,  be- 
sides, are  of  abnormal  duration  and  intensity,  and  have  a  further  injurious 
effect  through  the  influence  of  the  vasomotor  functions  which  stand  in  such 
intimate  relation  with  the  emotional  life. 

The  principal  soiuce  of  emotionality  lies  in  the  feeling  of  being  ill  and 
disturbances  of  sensation  (reduced  niUjScle-tone,  diminished  physical  and 
mental  power  of  activity,  and  the  consequent  involvement  of  self-confidence). 
The  ideas  are  necessarily  under  the  influence  of  this  state  of  feeling,  and  it 
thus  becomes  nosophobic,  which  temporarily  may  take  on  the  features  of 
actual  imperative  ideas. 

The  concrete  content  of  the  latter,  as  a  rule,  is  to  be  referred  to  somatic 
processes.  A  frequent  idea  of  this  kind  is  that  of  losing  the  reason,  a  noso- 
phobic erroneous  interpretation  of  pressure  in  the  head,  or  inhibition  of 
thought.  Others  are  ideas  of  threatening  apoplexy,  of  sudden  danger  in  gen- 
eral, associated  with  palpitation,  feeling  of  oppression,  globus,  etc.  Such  pa- 
tients then  hardly  trust  themselves  out  of  the  house,  in  carriages,  to  remain 
in  a  closed  room,  or  to  walk  in  a  deserted,  open  space.  In  a  similar  manner, 
there  are  ideas  of  danger  from  an  approaching  storm,  in  looking  at  poisons, 
metals,  dogs,  etc. 

Such  ideas  have  a  noteworthy  efl'ect  upon  the  feelings  (anxiety,  oppres- 
sion), upon  thought  (confusion),  the  will  (incapability  to  act),  the  vascular 
system  (vascular  spasm,  pallor,  palpitation),  iipon  the  secretory  organs  (diar- 
rhea, vesical  spasm,  diminution  of  the  salivary  secretion,  perspiration),  and 
upon  the  muscle-tone   (weakness  of  the  legs,  trembling,  etc.). 

At  the  height  of  the  emotional  state  the  idea  of  danger  may  become  an 
actual  delusion  with  the  apprehended  event  as  actually  taking  place,  to  be 
fully  corrected  only  when  quiet  is  restored.  In  all  directions  the  activity  of 
ideas  is  interfered  with  because  of  inhibitory  processes.  Apperception  is  also 
faint  and  temporarily  may  be  without  the  coloring  of  accompanjang  feelings. 
Thought  is  rendered  difficult  and  may  reach  complete  lack  of  comprehension, 
and  fatigue  comes  on  quickly.  Reproduction  is  indistinct  (weakness  of  mem- 
ory), and  judgment  is  difilcult  and  uncertain. 

The  feeling  of  weakness  and  the  disease  paralyze  the  energy  and  activity 
of  such  patients  and  render  them  lacking  in  courage,  inconstant,  cowardly,  re- 
laxed, and  indecisive,  even  to  the  extent  of  temporai-y  incapability  of  self- 
guidance. 

Sleep  suffers  almost  always,  in  that  the  psychic  organ  comes  to  rest  with 
difficulty,  owing  to  the  continuance  of  psychic  stimuli  (affects,  ideas,  fancies — 
going  even  to  formal  cerebral  erethism)  or  on  account  of  physical  processes 
(palpitation,  feeling  of  pulsation,  muscular  unrest,  etc.),  and  frightful  dreams 
often  interrupt  it.  In  general,  sleep  is  light,  unrefreshing,  and  more  like  a 
state  of  half-sleep,  as  if  brought  on  by  narcotics.  Sometimes,  on  the  otlier 
hand,  it  is  abnormally  deep  and  long-continued. 


448  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  sensorial  disturbances  consist  partly  of  symptoms  of  irritable  weak- 
ness (hyperesthesia,  emotional  coloring  of  impressions,  extreme  exhaustibility 
of  the  functions,  going  to  the  extent  of  extreme  exhaustion),  partly  of  those 
of  subjective  excitement  (vioiiches  rolaiiics,  tinnitus,  etc.).  Neurasthenic  as- 
thenopia is  a  very  troublesome  symptom. 

Sensory  disturbances  are  very  frequent  symptoms.  Cutaneous,  as  well  as 
muscular  and  visceral  paralgias,  are  the  most  frequent.  Then  come  neuralgias 
and  paresthesias.  Anesthesias  are  infrequent.  These  sensory  disturbances  do 
not  afTect  any  particular  nerve  territory.  A  very  important  symptom  in  such 
conditions  is  spinal  irritation. 

Expressing  the  disturbed  state  of  general  feeling,  there  are  great  fa.tigue, 
feebleness,  and  quick  exhaustion  in  such  patients.  These  cannot  be  regarded 
as  phenomena  related  to  fatigue.  They  are  often  more  pronounced  in  the 
morning  after  waking,  and  in  general  are  markedly  dependent  upon  psj'chiu 
influences. 

Frequently  there  are  central  vagus  manifestations  in  the  sense  of  chang- 
ing bulimia  and  anorexia  and  digestive  and  secretory  gastric  disturbances. 
The  frequent  desire  for  stimulants  is  remarkable,  which  temporarily  better 
the  neurotic  condition  (alcohol,  tobacco,  coca,  etc.).  This  gives  rise  to  the 
danger  of  abuse  of  them,  with  chronic  intoxication.  Too,  idiosyncrasies  with 
respect  to  food  and  intolerance  of  certain  drugs  (iron,  narcotics)  are  not  infre- 
quent. The  vita  sexualis  is  reduced  in  activity,  notwithstanding  episodic 
states  of  excitement. 

Vasomotor  disturbances  play  an  important  role.  The  irritable  weak- 
ness— i.e.,  the  abnormal  impressionability  and  rapid  exhaustion  of  the  vaso- 
motor system — is  indicated  by  the  changing  color  of  the  face,  the  variations  in 
the  distribution  of  the  blood  (vascular  spasm)  in  the  extremities,  often  con- 
tracted pulse  going  to  the  extent  of  local  asphyxia,  the  varying  feelings  of 
heat  and  cold,  the  oppression  of  the  heart  that  may  reach  the  intensity  of 
angina  pectoris,  and  the  precordial  distress  (vascular  spasm  in  the  domain  of 
the  cardiac  arteries?).  Probably  a  painful  feeling  of  dullness  and  pressure  in 
the  head  (head-pressure)  depends  upon  a  local  vascular  spasm,  which,  for  the 
most  part,  is  accompanied  by  paralgias  and  increased  inhibition  of  the  psychic 
activity,  as  well  as  by  great  mental  depression. 

Phosphaturia,  oxaluria,  general  unilateral  or  partial  hyperidrosis,  defect- 
ive secretion  of  the  sebaceous  glands  (dry  skin)  and  of  the  secretions  in  the 
joints  (creaking  joints)  are  to  be  mentioned  as  among  the  secretory  disturb- 
ances. 

Reduced  muscle-tone,  rapid  exhaustion  with  a  feeling  of  stiffness  and 
defective  response  in  the  functionally  exhausted  groups  of  muscles,  actual 
diminution  of  innervation  (weak,  low  voice,  etc.),  tremor  and  fibrillary  twiteh- 
ings  are  to  be  mentioned  as  some  of  the  motor  distvirbances. 

The  reflexes  in  general  are  increased  as  a  result  of  functional  weakness  of 
the  inhibitory  mechanism  (twitching  on  falling  asleep,  increase  of  the  skin 
and  patellar  reflexes,  cramps  in  the  calves,  precocious  ejaculation,  pollution, 
vesical  spasm,  etc.). 

Chronic  nem-asthenia  is  almost  exclusively  based  on  a  neuropathic  taint. 
It  is  one  of  the  most  important  clinical  manners  of  expression  of  this  taint 
and  the  foundation  upon  which  develop  other  neuroses  (hypochondria  in  men, 
hysteria  in  women)   and  psychoses. 

Undoubtedly  this  neurosis  can  also  be  acquired  as  a  result  of  f^ute  severe 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        449 

disease,  mental  and  physical  over-exertion,  moral  and  physical  shock  (railway 
spine),  frequent  childbearing,  and  sexual  excesses,  especially  onanism. 

Special  forms  of  neurasthenia  may  be  described  as  cerebral,  spinal,  and 
visceral.  These  forms  may  occur  simultaneously  (general  neurasthenia),  or 
combined  in  various  ways,  or  one  after  another,  in  predisposed  individuals. 

Regional  ageneses,  in  Arndt's  sense,  may  form  the  predisposition  in  an 
individual  to  the  development  of  a  certain  form  of  neurasthenia.  Without 
any  question,  too,  special  exciting  causes  are  also  of  influence  in  this  sense. 

The  cerebral  form  occurs  readily  as  a  result  of  mental  over-exertion  of  all 
kinds  (mental  strain,  especially  in  connection  with  emotional  excitement,  etc.). 
In  this  form  the  disease-picture  is  especially  characterized  by  predominant 
mental  and  sensorial  functional  disturbances.  The  mental  inhibition  may 
extend  to  absolute  incapacity,  and  the  inhibition  of  feeling  may  reach  tho 
degree  of  psychic  anesthesia.  The  inhibition  of  apperception  may  reach  even 
the  degree  of  temporary  mental  blindness  and  mental  deafness.  I  have  even 
observed  amnesic  aphasia  and  agraphia.  The  depression,  which  is  never  want- 
ing, is  secondary,  in  contrast  with  that  of  melancholia,  although  there  may  be 
easy  transitions  to  the  latter. 

Imperative  ideas  frequently  occur,  with  pronounced  dysthymic  accom- 
panying manifestations,  even  with  suicidal  or  hostile  content  with  reference 
to  others.  Pressure  in  the  head  is  very  rarely  wanting  and  almost  regularly 
the  patient  has  nosophobic  ideas  of  brain  softening  or  threatening  insan- 
ity, which  have  a  most,  disquieting  effect  upon  his  mind.  Frequently  there  is 
asthenopia,  and  not  infrequently  cystospasm. 

Spinal  neurasthenia  is,  for  the  most  part,  the  result  of  physical  over- 
exertion, severe  diseases,  the  puerperal  state,  sexual  excesses,  or  emotional  ex- 
citement. The  patients  tire  easily,  feel  languid,  complain  of  paralgias  of  the 
skin,  muscles,  or  joints,  and  are  quickly  exhausted  after  slight  effort;  and 
thereafter,  owing  to  the  irradiation  to  vasomotor,  secretory,  and  cardiac 
nerves,  they  have  palpitation,  outbursts  of  perspiration,  and  feelings  of  appre- 
hension and  oppression.  The  deep  reflexes  are  increased.  Sleep  is  disturbed 
by  starts.  There  are  often  sensations  of  numbness,  disturbed  reaction  of  the 
muscles  to  the  will,  not  infrequently  paresthesias,  and  even  circumscribed 
anesthesia.  Spinal  irritation  is  especially  frequent,  and,  with  the  various 
other  spinal  functional  disturbances,  becomes  the  foimdation  for  notions  of 
spinal  disease,  which  are  often  desperately  obstinate. 

Among  the  visceral  neurasthenias,  that  of  the  heart  is  especially  to  be 
mentioned.  It  occurs  in  tainted  individuals,  or  those  that  are  already  as- 
thenic, as  a  result  of  emotional  excitement,  too  warm  baths,  or  excessive  use 
of  tobacco.  The  malady  consists  of  attacks  of  disturbance  of  cardiac  innerva- 
tion, and  symptoms  during  the  intervals.  The  attacks  consist  of  feelings  of 
arrest  of  the  heart,  Avith  paralgic  pain  and  pressure  and  vibration  in  the 
cardiac  region.  ÖAving  to  irradiation  to  the  vagus  a.nd  glosso-pliaryngeal, 
breathlessness,  globus,  etc.,  occur. 

The  patient  believes  his  end  to  be  near  by  apoplexy,  and,  becoming  des- 
perate, he  renders  his  condition  worse  by  this  emotional  influence.  After  a 
time,  the  condition  passes  off.  The  patient  is  tired,  exhausted,  remains  emo- 
tional, unstable  in  his  vasomotor  functions,  and  predisposed  to  new  attacks, 
disquieted  in  the  extreme  by  ideas  of  heart  disease,  and  sometimes  the  paralgic 
troubles  in  the  cardiac  region  cause  nosophobic  ideas  and  depression. 

29 


450  SPECIAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

Gastric  neurasthenia  consists,  in  part,  in  reaction  to  digestive  processes 
which  surpasses  the  physiologic  norm  (to  be  understood  as  a  result  of  the 
abnormal  increase  of  reflex  excitability  and  irradiation  of  stimuli,  especially 
as  they  affect  the  vasomotor  nervous  system) ;  in  part,  in  troubles  inde- 
pendent of  the  process  of  digestion  (gastralgia,  pyrosis,  inictus,  occasional 
vomiting  of  water  and  mucus,  feelings  like  globus,  bulimia  alternating  with 
anorexia,  constipation,  slow  pulse,  disturbed  sleep,  emotional  excitability,  and 
depression). 

The  digestive  troubles  and  reactions  are  dullness,  pressure,  cerebral  con- 
gestion with  feelings  as  if  intoxicated,  Hashes  before  the  eyes,  roaring  in  the 
ears,  nervous  excitation,  palpitation,  alternating  feelings  of  heat  and  cold, 
desire  for  sleep.  Besides  these  there  are  special  dyspeptic  troubles  (fullness 
in  the  region  of  the  stomach,  epigastric  sensations,  ructus,  bloating  sickness, 
pyrosis).  One  of  my  patients  said:  "I  became  conscioiis  of  the  whole  process 
of  digestion."  Naturally  such  patients  eat  as  little  as  possible.  This  may 
result  in  inanition.  Mental  over-exertion  and  excitement  while  taking  food, 
which  is  hastily  chewed  and  not  sufficiently  digested,  are  important  causes. 

One  of  the  most  noteworthy  forms  is  sexual  neurasthenia.  Its  causes  in 
men  are  sexual  excesses,  especially  onanism;  sexual  abstinence  with  lively 
libido,  which  results  not  infrequently  in  so-called  psychic  onanism;  sometimes 
chronic  gonorrhea  in  tlie  posterior  portion  of  the  uretlira.  Pollutions  mark 
the  beginning.  They  are  the  signs  of  increased  impressionability  of  the  ejacu- 
latory  center  in  the  lumbar  cord,  whether  this  be  primary  (not  due  to  sexual 
excesses)  or  secondary  and  dependent  upon  peripheral  irritation  (hyperes- 
thesia of  the  urethra,  prostate,  and  sacral  plexus).  At  this  stage  (local 
genital  neuroses)  the  irritable  weakness  of  the  center  also  shows  itself  in  the 
form  of  prematui-e  ejaculation  in  coitus.  Tliis  renders  coitus  impossible,  and 
has  a  depressing  effect  upon  self-confidence.  The  pollutions  have  a  shock- 
like, injurious  influence  iipon  the  central  organ,  and  awaken  in  the  patient 
fears  of  commencing  disease  of  the  spinal  cord,  the  more  since  the  symptoms 
of  a  neurosis  of  the  lumbar  cord  become  clearer  and  clearer.  The  result  may 
be  profound  hypochondria  and  melancholia.  Under  the  influence  of  these 
feelings  and  thoughts  there  is  an  inhibitorj'^  influence  exerted  upon  the  erec- 
tion center  (psychic  impotence). 

In  the  furtlier  coiu'se  there  is  greater  intensitj'  of  the  irritable  weakness 
of  the  center  in  the  lumbar  cord  (neuroses  of  the  lumbar  cord).  Stimuli  of 
all  lands  induce  more  frequent  pollutions,  which  constantly  increase  the  irri- 
table weakness.  The  imusually  intense  libido  awakens  erections,  but  the 
irritable  weakness  of  the  center  does  not  permit  sufiicient  and  enduring  erec- 
tion. Pollutions  lead  to  more  and  more  distincj;  spinal  neurasthenia.  Tliis 
and  the  impotence  have  a  very  depressing  effect,  and  induce  thoughts  of  tabes 
and  hypochondriac  depression.  Paralgias  and  neuralgias  in  the  domain  of  the 
lurabo-saeral  plexus  complete  the  picture  of  spinal  neurasthenia.  Where  thei'e 
is  predisposition,  this  develops  into  general  neurasthenia,  in  which  special 
accidental  peculiarities  may  give  rise  to  the  cerebral,  gastric,  and  other  forms. 
Neurasthenia  developed  upon  a  sexual  foundation  is  characterized  by  a  shy, 
depressed  character,  reduced  feeling  of  self-confidence,  hj'pochondriac  depres- 
sion with  fear  of  tabes,  by  lassitude,  reduced  muscle-tone,  paleness  associated 
with  a  good  condition  of  general  nutrition,  intention-tremor,  and  tremor  due 
to  embarrassment,  which  may  go  to  the  dt'gree  of  helplessness  and  ataxia  in 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        45I 

movement  as  soon  as  the  patient  knows  that  he  is  under  observation.  Besides, 
there  is  tendency  to  dyspepsia,  flatulence,  and  obstipation;  great  variations  in 
the  frequency  of  the  pulse,  which  may  reach  120  as  a  result  of  emotion  or 
physical  exertion;  great  instability  of  the  vasomotor  functions,  which  may 
go  on  occasionally  during  attacks  to  general  vascular'  spasm  with  violent  pal- 
pitation and  paroxysmal  distress  and  oppression  in  the  cardiac  region.  There 
are  also  the  symptoms  of  the  peripheral,  genital,  and  lumbar  neuroses,  with 
intensification  of  the  general  psychic  troubles  by  renewed  ejaculations. 

Sexual  neurasthenia  in  women  presents  a  pathogenesis  and  symptoms 
analogous  to  those  that  occur  in  men.  Here  sexual  excesses,  especially 
psychic  onanism,  play  no  small  part.  As  analogues  of  pollutions,  there  are 
lascivious  dreams,  which  induce  spastic  contraction  of  the  tubes  and  the 
uterus,  with  expulsion  of  secretions  of  the  genital  mucous  membrane  under 
lustful  excitement.  The  shock-like  efi'ect  of  these  processes  is  the  same  as  that 
of  pollution  in  the  asthenic  male.  Besides  functional  and  organic  affections  of 
the  vagina,  the  uterus  and  ovaries  are  important  etiologically ;  for  they  induce 
hyperesthesia  (analagous  to  that  of  the  urethra  and  prostate  in  the  male). 

Anatomically  it  depends  upon  the  effect  of  tumors,  infarcts,  faults  of 
position,  or  erosions,  which  through  pressure,  pulling,  or  denudation  of  nerves 
have  an  irritating  effect  (Hegar).  Too,  other  organs  supplied  from  the 
pudendo-sacral  plexus  may  have  a  like  effect  (bladder  troubles,  rectal  fissures, 
hemorrhoids).  The  stages  are  genital  local  neurosis,  lumbar  neurosis  with 
spinal  irritation  never  wanting,  and  general  neurosis  (neurasthenia,  with 
mixture  of  symptoms  of  hysteria). 

Not  infrequently  the  disease  dates  back  to  the  development  of  puberty 
(agenesis  and  congenital  anomalies  in  the  position  of  the  uterus)  or  to  the 
climacteric.  At  the  time  of  the  menses  the  neurotic  troubles  are  alM'ays  in- 
tensified. According  to  Hegar,  the  conditions  which  point  to  a  neurosis  of 
genital  origin  are:  commencement  of  the  disease  with  symptoms  referable  to 
the  lumbar  cord;  occurrence  of  symptoms  in  domains  which  are  principally  in 
relation  M'ith  the  sexual  sphere  (stomach,  throat,  breast,  larynx,  thyroid, 
trigeminus)  ;  attacks  of  the  disease  beginning  with  aura-like  sjmiptoms  in  the 
path  of  the  nerves  of  the  lumbar  and  sacral  plexuses,  with  exclusion  of  anoma- 
lies or  diseases  of  other  parts  of  the  body  that  might  be  the  source  of  the 
neurosis. 

The  treatment  of  these  protean  forms  of  neurasthenia  must  be  princi- 
pally psychic  and  directed  to  the  causes.  Therapeutic  efforts  must  be  directed 
against  the  irritable  weakness  by  the  use  of  tonics  in  the  broadest  sense  of 
the  word. 

The  diet  must  be  rich,  especially  in  proteids  and  fat.  Stimulants  in  gen- 
eral are  to  be  avoided.  Among  physical  remedies  the  most  important  place  is 
to  be  given  to  fresh  air  (sojourn  in  the  mountains),  hydrotherapy,  rubbings, 
half-baths,  river  and  sea  bathing,  and  electricity  (general  faradization,  electric 
baths).  Among  drugs  indicated  are  iron,  arsenic,  strychnine,  phosphorus, 
ergot,  opium,  zinc,  cocaine,  damiana,  and  quinine,  in  accordance  with  the  indi- 
cations of  the  individual  case.  Valuable  sedatives  from  a  symptomatic  stand- 
point are  the  fluid  extract  of  piscidia  and  the  bromine  salts.  As  hypnotics, 
paraldehyde  comes  first,  and  then  amyl  hydrate  and  sulphonal.  Chloral 
hydrate  should  be  used  only  occasionally.  Where  the  nutrition  is  ffiuch  re- 
duced, as  in  certain  forms  of  gastric  neurasthenia,  forced  feeding  (Playfair)  is 


453  SPECIAL  TATHOLOGY  AND  TIIERArY  OF  INSANITY. 

indicated.     Here  the  detailed  treatment  of  single  forms  of  neiirastlioiiia  cannot 
be  considered. 

The  Psychoses  Based  uroN  a  Xeurastiienic  Coxditiox. 

Neurasthenia,  like  the  other  general  neuroses,  forms  a  great  pre- 
disposition for  the  origin  of  episodic  psychoses  or  those  that  develop 
as  terminal  phenomena.  These  jisychoses  may  he  divided,  with  con- 
siderahle  distinctness,  into  two  groups,  one  of  which  may  he  regarded 
as  psychoneurotic,  the  other  as  degenerate. 

Cases  of  the  second  group  actually  develop  only  upon  the  foim- 
dation  of  marked  taint,  of  which  chronic  constitutional  neurasthenia 
is  a  principal  feature.  The  psychoneurotic  group  is  made  up  of 
cases  in  which  predisposition  is  slight  or  entirely  wanting,  and  in 
which  the  neurasthenic  condition  is  acquired,  rather  episodic,  and 
in  any  event  not  constitutional.  The  psychoses  of  this  group  are  in 
part  transitory  and  in  part  prolonged.  The  protracted  psyclio.-es 
manifest  themselves  in  the  well-known  forms  of  melancholia,  stupid-^ 
ity,  and  confusional  insanity,  which  have  heen  described  with  the 
])syclioneuroses.  The  majority  of  the  cases  of  the  last  two  disease- 
pictures  are,  at  any  rate,  founded  upon  a  benign,  though  neuras- 
thenic, condition.  Under  degenerate  neurasthenic  disease-pictures 
we  shall  have  to  mention :  Insanity  with  imperative  conceptions  and 
the  clinically  peculiar  forms  of  paranoia  developed  upon  the  special 
foundation  of  neurasthenia.  Cases  of  melancholic  folic  ralsoiuiaiUe 
also  in  greater  part  belong  here. 

PsYCnONEUROSES  ON"  A  KeURASTHEN-IC  BaSIS. 

1.  Transitory  Insanity. 

This  mental  disturbance  sometimes  occurs  at  the  height  of  cere- 
bral neurasthenia  as  a  culminating  point  of  a  state  of  cerebral  ex- 
haustion, which  is  accompanied  also  by  external  signs  of  inanition 
and  exhaustion  (tremor,  subnormal  temperature).  Por  the  most 
part,  in  such  cases  we  have  to  deal  with  accpiired  and  more  or  less 
aciite  cases  of  neurasthenia.  The  final  cause  of  transitory  insanity 
is  sleepless  nights,  which  induce  the  expenditure  of  the  last  vestiges 
of  force.  It  quickly  disappears  with  the  restoration  of  slee})  and  im- 
proved nutrition. 

Exhaustion  of  the  psychic  organ  expresses  itself  in  clouding  of 
consciousness,  which  may  go  to  the  extent  of  loss  of  consciousness 
with  corresponding  defects  of  memory;  in  defects  of  the  sensorial 
functiofts,  which  may  reach  the  degree  of  want  of  apperception  and 
loss  of  speech  and  mol(jr  ideas.     Apprehension  and  single  delirious 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        453 

ideas  occur  in  this  temporary  state  of  niental  exhaustion,  wliicli  may 
increase  to  stupor,  and  these  ideas  may  lead  to  drcamj'',  insane  acts. 
Thus,  there  are  states  of  delirious,  clouded  consciousness  and  dream- 
like, stuporous  conditions  which  correspond  perfectly  with  those 
arising  upon  an  epileptic  foundation;  but,  with  regard  to  progno- 
sis, treatment,  and  the  future  condition  of  the  patient,  they  must  be 
sharply  differentiated  from  the  latter.  With  the  disappearance  of 
the  cerebral  exhaustion,  usually  as  a  result  of  sufficient  sleep,  lucidity, 
with  correction  of  the  false  ideas,  is  quickly  restored. 

The  pupils,  which  are  usually  dilated  and  react  slowly,  point  to 
an  anemic  state  of  the  brain  as  the  cause  of  this  transitory  insanity. 
The  possibility  of  cerebral  anemia  due  to  vasomotor  spasm  is  sug- 
gested by  the  small  pulse  and  wire-like  contracted  arteries.  These 
conditions  last  not  longer  than  a  few  days.  There  are  preceding  and 
following  them  clear  signs  of  severe  cerebral  neurasthenia.  Eelapses 
are  infrequent. 

Case  39. — Transitory  neurasthenic  insanity.  Delirium  with 
self-accusation. 

In  the  night  of  November  17th  to  18th,  the  police  foiind  A.  (aged  19)  in 
the  street,  naked  and  apparently  disturbed  mentally.  When  taken  to  the 
station,  he  ran  wildly  into  the  room  and  asked  to  be  tied  because  he  had 
stolen  money  and  clothing  from  his  superior. 

When  he  was  brought  into  the  clinic  of  the  Vienna  General  Hospital  he 
seemed  troubled,  but  his  conduct  was  otherwise  orderly,  and  there  was  no  dis- 
turbance of  association  of  ideas  within  the  circle  of  his  delusion.  He  repeated 
his  self-accusations.  He  had  stolen  yesterday,  had  been  immediately  arrested 
and  sentenced  to  fourteen  months'  imprisonment.  In  the  hospital  he  believed 
himself  in  prison,  and  took  the  physician  for  an  officer  of  the  law  who  had 
conducted  his  trial  the  day  before.  He  begged  for  lessening  of  the  sentence, 
knew  nothing  of  his  having  dropped  the  clothing  in  the  street,  but  thought  it 
was  qiiite  proper,  since  it  had  been  stolen. 

The  patient  is  of  medium  size,  thin,  badly  noiirished;  cranium  and  teeth 
rachitic.  Circumference  of  the  head,  56  centimeters.  Skull  not  sensitive. 
Complained  of  pressure  in  the  head.  Cranial  nerves  and  vegetative  organs 
without  anomaly.     No  fever.     Peropodia  on  the  left  side. 

At  half-past  11  on  the  morning  of  the  18th  the  patient  suddenly  came 
to  himself.  He  knew  where  he  was,  then  recognized  time,  and  the  last 
anomaly  to  disappear  was  the  delirium  of  self-accusation. 

Tlae  patient  is  lastingly  amnesic  for  the  time  between  7  o'clock  of  the 
evening  before  to  his  coming  to  himself  in  the  clinic.  He  hears  what  is  told 
him  of  Avhat  has  taken  place  with  an  air  of  astonishment  and  cannot  explain 
his  deliria.  He  remembers  indistinctly  that,  on  the  17th,  after  dinner  and  at 
about  4  o'clock,  he  had  gone  into  the  city  and  taken  something  in  a  cafe; 
memory  disappeared  from  this  moment. 

The  patient  came  of  a  neuropathic  mother,  father  was  a  drinker,  and  a 
sister  suffers  with  cerebral  infantile  paralysis.     Since  childhood,  the  patient 


454  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

has  been  nervous  and  excitable.  From  his  fourteenth  year,  he  sud'ered  with 
oplithalmic  migraine,  during  which  he  was  slightly  confused,  and  formerly  he 
hail  peculiar  ideas  of  being  rich,  but  lately  painful  thoughts,  which  had  actual 
foundation,  but  occurred  only  diuüng  the  attack  of  migraine.  He  was  also 
troubled  by  imperative  ideas  at  the  same  time.  The  scotoma  often  lasted  two 
or  three  hours,  the  attack  itself  even  twelve  hours.  Such  attacks  occurred 
tluee  or  four  tinres  a  year.  For  two  years  the  patient  had  been  employed  in 
the  office  of  a  lawyer.  He  was  not  a  drinker,  nat  given  to  sexual  excesses, 
and  iiatl  always  been  intolerant  of  alcohol. 

For  a  j'ear,  as  a  result  of  overwork  in  his  eiiipl(iyincnt.  lie  luul  had  ccro- 
brasthenia,  complaining  evenings  of  great  fatigue,  diffuse  headache,  and 
dillicultj'  of  thought.  He  was  sleepless,  increasingly  disgusted  with  work,  and 
incapable.  He  complained  that  he  must  maintain  an  old  mother  and  employ  all 
his  will-power.     He  was  afraid  for  the  future  that  he  would  become  a  begga,r. 

During  the  last  six  months  there  had  been  distress  in  the  family,  which 
weighed  much  upon  him.  The  patient  worked  nevertheless  nine  hours  a  day 
in  the  office,  and  spent  his  time  in  the  evening  reading,  usually  until  3  o'clock 
in  the  morning.  He  was  forced  to  rise  tired  and  exhausted  at  7  o'clock  in  the 
morning  and  resume  his  work.  Of  late,  preceding  the  mental  trouble  there 
had  been  little  sleep,  and  much  pressure  in  the  head  with  increasing  irrita- 
bility. When  he  went  out  on  the  evening  of  the  17th  he  had  no  migraine. 
On  the  way  thoughts  suddenly  came  to  him  that  he  was  a  criminal,  which  he 
was  able  to  overcome  easily  by  his  consciousness  of  innocence. 

At  his  desire,  because  he  might  lose  his  position,  the  patient  was  dis- 
charged on  November  19th.  At  this  time  the  patellar  reflex  was  much  in- 
creased, and  there  was  left  foot-clonus.  On  November  21st  the  patient  re- 
turned to  the  police  department  because  he  again  had  imperative  ideas  of 
being  a  criminal,  which  troubled  him.  With  antineurasthenic  treatment  and 
care  for  sleep  these  troubles  disappeared. 

2.  Profracled  Psychoneurotic  Forms  of  Disease. 

Following  immediately  "upon  the  transitory  states  of  exhaustion 
of  the  neurasthenic  hrain  are  to  be  considered  the  disease-pictures  of 
stupidity  (acute  dementia)  and  confusional  insanity,  as  most  instances 
of  the  latter  disease  belong  in  this  category.  Manias  developing  in  a 
neurasthenic  brain  are  very  infrequent.  Apparently  in  such  condi- 
tions the  absence  of  nervous  force  is  not  sufficient  for  the  develop- 
ment of  maniacal  states.  Melancholias  are  much  more  frequent 
upon  a  neurasthenic  basis.  As  an  example  of  such  melancholias, 
characterized  more  by  inhibition  than  by  psychic  pain,  is  that  due 
to  onanism. 

Melancliolia  Masturhatoria. 

This  develops  upon  the  basis  of  a  cerebral  neurasthenia  pro- 
voked by  sexual  neurasthenia.  The  stage  of  incubation  corresponds 
with  the  picture  of  a  psychoneurosis  with  dysthymia  and  never-failing 
nosophobic  interpretation  of  head-pressure  and  ideational  inhibition 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        455 

(threatening  insanity),  of  spinal  irritation  (tabes),  or  disturbed  sex- 
ual function  (incurable  impotence).  The  condition  develops  slowly 
to  the  height  of  the  psychosis,  or  acutely  as  a  result  of  psychic  shock 
(especially  fright,  knowledge  of  the  results  of  the  vice).  Self-confi- 
dence is  profoundly  diminished.  The  patient  thinks  that  he  is  recog- 
nized as  one  given  to  onanism  and  therefore  despised.  He  feels  in 
a  painful  way  that  he  is  the  object  of  attention.  As  a  result  of  olfac- 
tory hallucinations  he  thinks  that  he  gives  forth  foul  odors  and  is 
therefore  avoided.  The  psychic  pain  is  much  less  a  spontaneous 
symptom  than  a  reaction  to  the  symptoms  of  mental  inhibition.  The 
patient  is  pathetic  and  theatric  in  the  expression  of  his  sufferings  and 
his  guilt.  He  poses  less  as  a  repentant  sinner  than  as  a  martyr  to  a 
fatality,  and  this  may  be  accompanied  by  religious  ideas.  In  his 
outbreaks  of  despair  there  is  frequently  great  irritability,  which  may 
extend  to  aggressive  acts  toward  others. 

Occasionally  there  are  noticed,  especially  at  night,  attacks  of 
apprehension  due  to  cardiac  neurasthenia  and  vasomotor  angina  pec- 
toris, which  may  reach  the  degree  of  raptus  melancliolicus.  Attempts 
at  suicide  in  such  patients  are  quite  usual.  They  should  always  be 
expected.  Not  infrequently,  apparently  as  a  result  of  repentance,  and 
partly  with  a  thought  to  save  themselves,  mutilation  of  the  genitals 
occurs.  The  impossibility  of  resisting  the  deep-rooted,  though  feared, 
imj^ulse  to  onanism  and  the  painful  inhibition  of  volition  and  thought 
are  not  infrequently  interpreted  as  evidence  of  being  possessed  by 
the  devil,  which  may  develop  into  true  demonomania  with  corre- 
sponding delusions  and  hallucinations. 

On  the  basis  of  profound  degeneracy  are  observed,  with  remark- 
able frequency,  uncleanliness,  impulse  to  disgusting  things,  impulsive 
raptus,  imperative  ideas,  and  primordial  delusions — usually  of  re- 
ligious content  (Messiah). 

Episodic  transformation  to  hallucinatory  confusional  insanity, 
owing  to  the  neurasthenic  foundation  of  these  conditions,  is  not  in- 
frequent. The  common  features  which  indicate  the  special  cause  of 
the  disease  are  shown  in  the  personality,  which  is  relaxed,  mentally 
and  physically  broken,  shy,  with  sentimentality  and  inclination  to 
religion  and  mysticism;  somatically,  by  the  neurasthenic  troubles, 
especially  pressure  in  the  head,  spinal  irritation,  and  the  hallucina- 
tions of  smell,  which  are  rarely  wanting.  The  prognosis  is  not 
unfavorable.  Tonics,  with  opium,  which  here  usually  has  an  excellent 
effect,  hydrotherapy,  and  care  of  the  patient  to  prevent  onanism  are 
the  principal  indications  in  treatment.  I  have  not  noted  any  differ- 
ence between  the  disease-picture  as  presented  in  men  and  women. 


456  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Case  40. — Melancholia  due  to  onanism. 

Miss  S.,  aged  23.  Mother  neuropathic.  Mother's  brother  died  in  an 
insane  asylum.  One  sister  died  in  convulsions.  Patient  is  said  to  have  de- 
veloped normally  and  to  have  presented  nothing  abnormal,  except  a  choleric 
disposition.  Pubertj^  began  at  14  without  difliculty.  The  patient  was  tal- 
ented, especially  for  music,  was  well  educated,  and  had  no  severe  disease  until 
August,  1882.  At  that  time  neurasthenia  developed  (quick  mental  and  phys- 
ical exhaustion,  complaints  of  pressure  in  the  head,  spinal  irritation,  bad  and 
unref resiling  sleep).  Patient  lost  her  former  gayety,  lost  weight,  developed 
dyspeptic  symptoms,  became  depressed,  irritable,  and  often  stared  before  her 
and  expressed  disgust  with  life.  She  neglected  her  appearance,  showed  lack  of 
interest  in  employment,  even  leaving  her  music,  which  she  formerly  had  culti- 
vated passionateh'.  In  the  course  of  the  spring  of  1883  the  patient  became 
more  and  more  abulia  and  inactive,  anemic,  dominated  by  numerous  paralgic 
sensations,  hypochondriacally  depressed,  would  not  eat  because  nothing  could 
pass  througli  her  alimentary  tract,  expressed  the  fear  that  she  was  sull'eriiig 
with  cancer  and  would  infect  others,  and  therefore  she  kept  more  and  more 
apart  from  her  relatives.  With  this  there  was  decided  decrease  of  general 
nutrition  and  profound  anemia. 

In  May,  1883,  raptus-like  attacks  of  apprehension  occurred  in  which  she 
attempted  suicide  by  jumping  into  the  water.  "When  saved  she  expressed 
profound  repentance,  and  thought  that  her  sins  could  no  longer  be  forgiven. 
She  herself  was  the  cause  of  her  own  misfortune,  felt  that  she  was  losing  her 
reason,  could  not  think  (head-pressure).  She  thought  she  would  lose  her 
reason  and  die  of  cancerous  disease,  the  odor  of  which  she  perceived  already. 
She  bemoaned  in  a  sentimental  way  her  ruined  life,  her  early  death,  asked  that 
she  be  pitied,  and  that  she  be  punished  because  she  deserved  it.  Since  she  was 
constantly  losing  in  physical  strength  and  frequently  refused  food,  and  the 
raptus-like  attacks  of  fear  recurred,  the  patient  was  admitted  to  the  clinic  in 
the  beginning  of  August,  1883. 

On  admission,  the  patient  is  pale,  anemic,  thin,  Avith  circles  around  the 
eyes,  dirty  color,  with  numerous  abrasions  on  the  face  and  hands  due  to 
scratching.  The  skull  is  regularly  formed  and  there  are  no  signs  of  degenera- 
tion. The  vegetative  functions  are  normal.  Tired,  exhausted,  shy  character; 
relaxed,  bent  attitude.  The  patient  has  niunerous  sensations  and  uncomfort- 
able bodily  feelings.  She  one  day  had  felt  that  her  spirit  was  going,  and  in 
her  fear  of  not  being  able  to  live  long  she  had  sprung  into  the  water.  Her 
body  feels  like  a  stone  stuffed  full  of  food.  Her  body  is  quite  destroyed;  she 
can  no  longer  think  and  feels  that  she  is  nothing;  that  she  is  full  of  lice 
which  the  nurses  have  fed  her.  She  is  as  heavy  as  lead.  She  had  destroyed 
herself  by  her  sin  (onanism)  and  was  guilty  of  everything.  With  that, 
weeping,  saying  if  she  only  had  a  husband!  Asked  to  have  her  throat  cut. 
She  is  already  rotting  and  has  been  dead  a  long  time.  She  does  not  under- 
stand how  anyone  could  wish  to  make  one  who  is  dead  still  eat.  She  is  a 
gi-eat  sinner.  There  is  nothing  left  for  her  to  do  but  to  be  delivered  to  hell. 
The  train  in  which  she  had  traveled  would  be  destroyed  on  her  account,  and 
also  the  whole  city  of  Gratz.  Visions  of  the  devil,  mistaking  those  around 
her  for  the  devil.  Anxious,  apprehensive  state  of  expectation  with  reference 
to  the  joiirney  to  hell.  Episodically,  painfully  sentimental  complicated  states 
of  feeling  with  recourse  to  religion,  mistaking  physicians  for  Christ  and  a 
fellow-patient  for  the  Virgin  Mary. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        457 

The  patient  is  kept  in  bed,  fed  well,  and  treated  with  iron  and  quinine. 
Defective  sleep  is  combated  with  paraldehyde.  The  neurasthenic,  hypochon- 
driac, melancholic  disease-picture  at  times  approaches  that  of  hallucinatory 
confusion:  incoherent  delirium,  exhaustion,  numerous  demoniac  visions.  Illu- 
sory mistaking  of  those  around  her  for  divine  persons.  Persecutory,  denuncia- 
tory voices.     Hallucinations  of  smell,  of  putrefaction,  of  decaying  flesh,  etc. 

After  a  few  weeks,  with  improvement  of  the  general  nutrition,  the 
original  picture  of  melancholia  returned  with  predominating  manifestations  of 
inhibition  and  allegoric  interpretation  of  them.  The  patient  complains  that 
she  is  absolutely  foolish  and  does  not  know  what  she  should  do.  She  thinks 
herself  at  the  end  of  the  world.  All  is  dead.  She  would  prefer  to  be  buried 
than  eaten  by  the  mice.  She  feels  how  she  is  already  bitten  by  the  worms 
(paralgias).  She  asked  whether  she  would  not  finally  be  hacked  to  pieces  and 
slaughtered.     She  says  that  she  is  guilty  of  everything. 

In  the  course  of  October,  decided  improvement.  The  patient  gains  in 
weight,  and  her  turgor  vitalis  and  color  return  and  she  shows  interest  in  the 
external  world,  asking  for  news  of  home.  Episodically  she  is  still  a  great 
sinner.  She  thinks  herself  too  well  cared  for  and  belongs  in  hell.  Continued 
improvement  under  rubbings  with  wet  towels,  strengthening  diet,  and  tonic 
medication. 

The  middle  of  November  the  complaints  of  herself  decrease.  Sentimental, 
painful  feelings  concerning  herself  and  the  world  take  their  place.  The  dis- 
ease returns  to  its  original  phase  of  a  hypochondriac  neurasthenic  neurosis: 
Complaints  of  mental  confusion.  Destroyed  power  to  think.  Empty  head. 
Hypochondriac  ideas  of  cancer  and  pyemic  fever  due  to  occasional  hallucina- 
tions of  smell  and  paralgias,  especially  of  spinal  irritation.  Pressure  in  the 
head  v/ith  complaints  that  the  brain  has  disappeared.  Gradually  there  is  in- 
sight into  the  disease  and  return  of  former  inclinations  and  occupations.  At 
times  exacerbations  of  the  inhibition,  depression,  the  paralgic,  neurasthenic 
troubles,  and  renewed  hallucinations  of  hearing  which  can  ahvays  be  referred 
to  onanistic  relapses.  With  hydrotherapy,  iron,  constant  watching  day  and 
night,  recovery  gradually  takes  place.  On  March  1,  1884,  the  patient  was  dis- 
charged recovered.  In  the  fall  of  1886  I  saw  Miss  S.  on  the  occasion  of  a 
visit,  and  she  was  a  bright,  fresh  young  lady,  physically  and  mentally. 

8.  Degenerate  Forms  of  Disease  upon  a  Neurasthenic  Basis. 

As  striking  types  to  be  described  here,  there  are  peculiar  forms 
of  mental  disturbance  characterized  by  imperative  ideas  and  disease- 
pictures  of  paranoia. 

(a)  Mental  Disturbance  Due  to  Imperative  Ideas?- 

In  contrast  with  the  elementary  and  episodic  depression  in 
tainted,  neurotic,  melancholic  patients  having  imperative  ideas  (camp. 
page  63),  here  we  have  to  deal  with  lasting  and  innumerable  proc- 


^  Synonyms :  abortive  Verrücktheit,  folic  du  doute  avec  delire  du 
toucher,  folic  avec  conscience,  pseudomonomanie,  impulsions  intelleetueUes, 
folic  ii  idees  imposees,  delire  emotif. 


458  SPECLrVL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

esses  which  attack  the  personality,  and  in  all  directions  of  the 
mental  life  have  partly  an  inhibitory,  partly  a  disturbing  and  com- 
pelling effect,  which  moreover  present  a  peculiar  course,  and  thus 
have  the  significance  of  a  special  and  very  characteristic  disease- 
picture. .  The  effect  upon  thought  is  inhibitory;  upon  feeling,  dis- 
turbing, and  to  such  a  degree  as  to  induce  despair;  on  the  psycho- 
motor side  there  are  impulses  to  act  in  the  sense  of  the  concrete 
imperative  idea,  or  to  hinder  intended  acts. 

This  insanity  of  imperative  idea  rests  xipon  a  neurotic  foundation.  As 
a  rule,  this  can  be  shown  to  be  neurasthenia — i.e.,  constitutional  and  due  to 
heredity;  and  upon  this  foundation  there  may  develop  an  hysteropathic  or 
hypochondriac  picture  as  an  accompanying  neurosis  of  the  process  of  impera- 
tive ideas.  It  is  only  in  rare  cases  that  the  neurasthenia,  either  with  or 
without  pronounced  hysteria  or  hypochondriac  symptoms,  is  acquired  (as  a  re- 
sult of  mental  overexertion,  emotions,  severe  exhausting  diseases  following 
quickly  upon  confinement,  lactation,  sexual  excesses,  especially  onanism,  etc.)» 
and  the  malady  under  certain  circumstances  is  teraporars\  Causes  which 
excite  the  outbreak  of  the  disease  or  relapses  are  the  weakening  influences 
already  mentioned. 

In  cases  which  develop  on  the  basis  of  hereditary  taint,  even  physiologic 
phases  of  life  (puberty,  climacteric)  suffice  to  induce  the  disease;  indeed,  not 
infrequently  it  occurs  in  childhood,  like  cases  of  original  paranoia. 

That  the  malady  runs  its  course  upon  a  neurasthenic  foundation  is  shown 
by  the  fact  that  the  immediate  causes  of  the  outbreak  are  influences  which 
reduce  the  cerebral  tone;  for  example,  emotions,  loss  of  blood  (menses),  in- 
dispositions, debauches,  and  the  like;  that  relapses  and  exacerbations  of  the 
disease  go  hand  in  hand  with  those  of  the  fundamental  accompanying  neurosis, 
while,  on  the  other  hand,  successful  treatment  of  the  nervous  weakness  im- 
proves the  mental  disease. 

The  disease  occurs  with  quite  the  same  frequency  in  both  sexes.  The 
imperative  ideas  of  the  disease-picture  under  consideration  have  many  things 
in  common  and  many  analogies  with  the  primordial  delusions  of  paranoia,  in 
that  they  are  primary  and  devoid  of  any  afi'ective  foundation,  even  though 
maintained  or  intensified  by  emotions;  that  they  develop  out  of  the  depth  of 
unconscious  mental  life  and  have  a  surprising,  disturbing,  and  strange  eflfect 
upon  the  conscious,  logical  content  of  thought,  with  which  they  stand  in  con- 
trast and  over  which  they  exercise  a  compelling  force.  A  fundamental  differ- 
ence, however,  consists  in  this:  that  the  primordial  delusions  of  parajioia  are 
quickly  accepted,  assimilated,  and  elaborated  into  a  system  of  delusions,  while 
the  imperative  ideas,  at  least  as  a  rule,  are  always  regarded  as  abnormal  and 
looked  upon  as  unassimilable  disturbing  invaders.  With  reference  to  the 
course,  there  are,  on  the  other  hand,  again,  some  analogies  in  that  the  in- 
sanity of  imperative  ideas  has  this  in  common  with  paranoia:  that  these 
genuinely  constitutional,  persistent,  and,  on  the  whole,  stationary  states  do 
not  progi-ess  to  pronoimced  conditions  of  psychic  weakness. 

On  the  psychic  side  in  these  cases  there  is  no  stage  of  incubation. 
In  the  midst  of  perfect  mental  health  the  patients  are  overcome  by 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        459 

thoughts  that  are  irrelevant  and  without  any  irnnKuliatc  relation 
to  any  affect,  but  which  remain  in  consciousness  with  abnormal 
intensity  and  duration,  in  spite  of  every  effort  of  the  will  and  thought, 
until  they  disappear  spontaneously.  Tbe  patient  tben  has  peace,  or 
a  new  fixed,  distressing  circle  of  ideas  takes  the  place  of  those  that 
have  disappeared.  This  is  the  more  to  be  feared  because  the  reac- 
tional,  emotional  state  induced  by  the  imperative  ideas  reduces  the 
activity  of  the  will  and  ideational  association,  and  especially  because 
the  excessive  mental  work  due  to  the  attack  increases  still  more, 
temporarily,  the  state  of  neurasthenia  and  irritable  weakness. 

The  immediate  cause  of  the  occurrence  of  concrete  imperative 
ideas  is  only  exceptionally  demonstrable.  They  may  arise  psycho- 
logically through  association  of  ideas  excited  by  a  sensory  perception; 
as  a  result  of  some  astounding  event  or  some  word  in  reading,  in 
prayers,  or  in  conversation ;  and  under  some  circumstances  as  a  result 
of  contrast  of  ideas.  As  a  rule,  the  manner  of  origin  is  probably 
physiologic  and  organic,  much  as  is  the  case  with  primordial  delu- 
sions; and  under  such  circumstances  the  primum  movens  in  the 
development  of  the  imperative  idea  is  difficult  to  discover.  In  some 
cases  a  connection  with  erotic,  lascivious  ideas  at  the  time  of  the 
menstrual  processes,  or  sexual  excitement,  may  be  proved;  or  a  con- 
nection of  a  destructive  imperative  idea  with  disturbances  of  bodily 
sensation  may  be  traced, — as,  for  example,  a  neuralgia,  with  which  in 
its  nascent  state  the  imperative  idea  becomes  connected.  The  con- 
tent of  imperative  ideas  is  extremely  varied,  corresponding  with  the 
mental  development  in  general  and  the  peculiarities  of  the  individual 
that  presents  them.  It  is  plain  that  original  anomalies  of  the 
character  favor  the  occurrence  of  this  or  that  order  of  imperative 
ideas;  as,  for  example,  religious  thoughts  in  bigots;  thoughts  of 
uncleanness  in  those  that  are  hysteric  or  hypochondriac;  thoughts 
about  everything  being  properly  cared  for,  whether  everything  is 
in  its  proper  place,  in  persons  who  have  been  remarkable  for  their 
pedantry  and  troublesome  sense  of  order.  On  the  other  hand,  the 
typic  correspondence  in  the  content  of  these  ideas,  as  well  as  the 
order  in  which  they  develop  in  individuals  of  different  positions  in 
life,  of  different  sex,  and  of  various  degrees  of  education,  like  the 
typic  primordial  delusions  of  original  paranoia,  is  astounding. 

We  are  justified  in  separating  as  a  distinct  disease-picture  in  thi? 
group  cases  in  which  there  is  at  first  the  impulse  constantly  to  think, 
usually  of  religious  and  metaphysical  matters,  and  in  which  later  the 
imperative  idea  of  being  soiled  by  metals,  animals,  and  the  like, 
occurs  (folie  du  deute  avec  delire  du  toucher — Legrand  du  Saulle). 


460  SPECML  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

These  imperative  ideas  are  the  most  frequent.  The  religious  content  is 
made  up  of  questions  like  these:  What  is  God?  Is  there  a  God?  How  was 
Eternity  created?  Why  is  there  a  devil?  Is  there  an  actual  devil?  Is  there 
such  a  thing  as  Eternity?  Is  there  a  Providence?  How  can  the  idea  of  three 
beings  in  one  person  be  reconciled?  Tlie  metaphysical  problems  are  similar: 
How  did  man  arise?     What  was  the  origin  of  the  world? 

Many  patients  are  forced  to  continually  occupy  themselves  with  mathe- 
niatic  questions,  and  to  carry  out  the  hardest  mental  problems,  until  they  are 
exhausted.  In  otlier  cases  each  sensory  perception  is  associated  with  the  ques- 
tion of  the  why  and  wlierofore  of  the  phenomenon;  or  what  would  happen  if 
the  patient,  for  example,  at  the  sight  of  a  knife,  should  cut  his  own  or  his 
friends'  throats;  or  if,  on  the  bank  of  a  stream,  he  should  push  some  one  into 
the  water.  AVhether,  in  the  first  case,  death  would  occur  immediately,  and 
how.  By  hemorrhage?  In  the  second  case,  whether  the  person  would  be  able 
to  save  himself  by  swinuning.  Or  there  may  be  hannless  imperative  ideas, 
such  as  whether  the  ladies  met  are  beautiful  or  ugly,  single  or  married. 

Others,  in  their  everyday  occupation,  are  constantly  occupied  witli  the 
thought  of  whether  they  do  their  duties  properly;  whether  a  letter,  for 
example,  was  correctly  and  clearly  written;  whether  there  were  any  faults  of 
spelling  in  it,  or  blots;  whether  the  address  was  properly  written;  whether 
the  letter  had  not  stuck  in  the  letter-box;  Avhether  a  sum  of  money  was  cor- 
rectly counted,  a  bill  correctly  made  out,  the  doors  actually  shut,  the  lights 
extinguished,  or  a  thief  had  not  stolen  in. 

With  these,  there  are  the  painful  imperative  ideas  and  scruples  as  to 
whether  this  or  that  act  or  neglect  might  not  be  injurious  to  the  patient's 
health  or  to  the  health  of  others.  The  thought  that  with  a  match,  a  pin,  a 
splinter  of  glass,  a  spot  of  ink,  the  health  and  life  of  another  has  been  affected 
tortin-es  such  a  patient,  whose  fancy  paints  the  most  absiu-d  results  of  his 
hypothetic  carelessness.  On  a  bridge  the  thought  comes  of  having  pushed 
some  one  into  the  water,  and  he  has  to  look  to  determine  wliether  some 
passer  has  not  fallen  into  the  water.  The  situation  may  become  intensified 
to  the  torturing  imperative  idea  of  having  murder  on  the  conscience. 

In  the  attempt  to  pray  the  opposite  idea  comes  up:  cursed  instead  of 
blessed;  hell  instead  of  Heaven;  wild  sow  instead  of  Our  Lady;  and  this 
happens  at  every  attempt  to  repeat  the  same  passage  of  thd  prayer.  After 
having  been  to  confession  the  patient  is  martyred  by  the  thought  of  having 
forgotten  sins,  and,  after  communion,  of  having  taken  commimion  unwortliily: 
of  having  allowed  a  part  of  the  Host  to  fall  on  the  ground.  After  having 
given  testimony  in  court  the  imperative  idea  comes  of  having  given  incorrect 
testimony  and  of  having  committed  perjury.  In  social  intercourse  there  is 
the  thought  of  having  said  or  done  something  compromising;  in  business,  of 
having  lost  compromising  papers.  In  shops  such  patients  are  troubled  with 
the  idea  of  having  hidden  objects  in  their  clothes,  or  of  accidentally  having 
carried  ofi"  objects  in  their  garments.  In  the  street  there  is  the  imperative 
idea  of  being  forced  to  blush,  and  thus  to  appear  ridiculous;  of  having  caused 
a  lamplighter  to  fall  from  his  ladder.  The  patients  are  forced  to  stand  for 
hours  to  see  whether  a  child  is  to  be  run  over;  whether  a  man  working  on 
the  roof  does  not  fall;  whether  a  bridge  does  not  give  Avay;  or  whether  all 
the  passers  have  the  luck  to  get  over.  In  the  further  coiu-se  of  the  disease 
there  frequently  develop  imperative  ideas  of  uncleanliness  arising  from  dirt 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        461 

and  poison.  The  sight  of  cats  and  dogs  awakens  the  idea  of  the  poison  of 
rabies;  the  sight  of  copper  vessels  or  metallic  door-bells  the  idea  of  verdigris. 
Tlie  patient  is  poisoned,  and  poisons  are  communicated  to  the  family;  all  are 
poisoned,  etc. 

The  imperative  ideas  are  not  always  absurd;  they  may  be  concerned  with 
actually  possible  experiences,  philosophic  problems,  mathematic  questions, 
etc.  Thus  one  of  my  patients  was  forced  for  months  at  a  time  to  keep  think- 
ing about  whether  his  fortune,  which  was  invested  in  State  bonds,  was 
actually  secure.  Under  all  circumstances  we  are  immediately  struck  by  the 
inability  of  such  patients  to  bring  these  thoughts  to  an  end;  by  the  forced 
impulsion  with  which  they  constantly  recur,  in  spite  of  the  fact  that  the 
patient  understands  the  improbability,  or  even  the  impossibility,  of  his  fears. 

The  formal  disturbance  of  ideas,  as  presented  in  imperative  con- 
ceptions, exerts  its  influence  upon  the  other  mental  functions.  In 
thought  it  inhibits  the  free  play  of  association,  and  prevents  the  oc- 
currence of  ideas  that  are  quieting  or  justified. 

The  influence  upon  action  and  feeling  is  especially  important. 
In  spite  of  perfect  lucidity,  in  spite  of  comprehension  of  the  abnor- 
mality of  the  process  and  the  uselessness  and  painfulness  of  the  im- 
perative thinking,  the  patient  is  constantly  forced  to  think,  to  ask 
questions,  to  go  over  events,  to  reassure  himself,  to  call  up  events 
again,  to  Aveigh  possibilities,  to  search  for  the  proper  word  in  prayer, 
etc.,  but  all  in  vain.  In  time  the  impulse  to  act  in  accordance  with 
the  impulsion  or  to  commit  acts,  becomes  associated  with  the  impera- 
tive conception. 

The  patient  is  forced  to  shield  himself  and  others  from  dangers,  to 
smooth  the  wrinkles  out  of  the  carpets,  to  take  the  stones  out  of  the  street 
so  that  no  one  can  sprain  his  ankle.  To  his  horror,  he  is  impelled  by  de- 
structive imperative  ideas  to  kill  himself  or  others,  to  commit  some  crime,  to 
shout  a  curse,  to  bite  the  Host,  to  spit  it  out,  etc.;  to  accuse  himself  before 
the  court  as  a  perjurer  or  murderer;  or  in  a  harmless  way  he  is  forced  con- 
stantly to  put  things  in  order  and  place  things  where  they  belong;  to  change 
his  thought,  to  Avash  himself  constantly,  or  to  remove  supposed  dust  or  poison 
from  his  clothing.  Thus  the  patient  loses  much  time  and  gradually  becomes 
incapable  of  carrying  on  his  employment.  He  now  is  no  longer  able  to  touch 
the  handles  of  doors  or  metal  vessels,  or  to  visit  the  church  or  the  theater,  be- 
cause he  may  commit  a  sin,  compromise  himself.  He  no  longer  dares  to  go 
out  in  the  street,  or  cross  bridges,  because  he  fears  to  do  others  hann ;  or  be- 
cause he  wishes  to  avoid  the  sight  of  the  streets  or  objects  which  might 
awaken  his  terrible  imperative  ideas. 

At  the  beginning  it  is  still  possible  for  him  to  go  about  by  avoiding 
streets  where  there  are  no  people,  to  go  out  at  night,  to  run  across  bridges,  etc. 

The  reactionary  effect  of  the  imperative  ideas  upon  the  emo- 
tional life  of  the  patient  is  especially  important.  The  result  is  vio- 
lent reactive  apprehension,  which  may  go  to  the  extent  of  outbreaks 


463  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

of  despair  and  nervous  crises  (contracted  pnlse,  tremor,  palpitation, 
fainting). 

The  apprehension  is  explained  by  the  painful  state  of  psychic 
strain  which  the  imperative  idea  engenders,  by  the  feeling  of  power- 
lessness  to  overcome  the  impulse,  and  by  its  painful  content,  when 
it  is  sacrilegious,  immoral,  or  criminal;  to  this  is  added  the  fear 
that,  with  diminishing  power  of  resistance,  the  impulse  connected 
with  the  imperative  idea  may  lead  to  the  commission  of  some  act  that 
is  silly,  compromising,  sacrilegious,  or  criminal;  and  finally  the  fear 
is  intensified  by  the  danger  of  letting  others  notice  this  painful  state, 
and  the  feeling  that  the  whole  thing  will  end  in  insanity. 

If  the  patient  is  able  to  yield  to  his  imperative  ideas,  or  to  sat- 
isfy some  impulse  which  would  find  expression  in  harmless  acts,  or 
to  weepj  then,  as  a  result  of  the  motor  or  secretory  reaction,  the 
painful  crisis  is  quickly  over  and  the  patient  soon  experiences  decided 
relief. 

The  general  course  of  the  malady  is  characterized  by  remissions 
and  exacerbations.  Intermissions  lasting  many  years  are  not  infre- 
quent. The  attacks  of  the  disease  occur  suddenly  and  disappear  in 
the  same  way.  After  a  series  of  numerous  paroxysms  there  is  usually 
a  longer  pause  of  rest  and  recuperation.  The  accompanying  somatic 
symptoms  of  the  disease  are  those  that  belong  to  the  fundamental 
neurosis.  As  in  the  neuroses  in  general,  in  this  trouble  there  are 
spontaneous  attacks  of  anxiety,  and  epileptic  phenomena  are  not 
infrequent. 

Melancholia  may  occur  episodically.  I  have  observed  one  case 
of  the  insanity  of  imperative  ideas  complicated  by  periodic  melan- 
cholia. Temporarily  the  critical  power  of  the  patient,  with  reference 
to  his  imperative  ideas,  may  be  in  abeyance,  and  they  may  then  pre- 
sent the  character  of  delusions.  The  terminations  of  the  disease  arc 
recovery  and  states  of  mental  torpor.  In  acquired  non-constitutional 
cases  I  have  repeatedly  seen  recovery,  but  in  others,  never,  though  I 
have  in  the  latter  observed  intermissions  lasting  years.  In  reality 
these  patients  remain  capable  of  intellectual  work,  but  their  inquiring 
disposition,  their  desire  to  have  everything  done  exactly  and  to  verify 
every  act,  do  not  allow  them  to  perform  the  ordinary  duties  of  lifo. 
Their  timidity  in  the  presence  of  things  or  surroundings  which 
would  tend  to  excite  their  imperative  conceptions  keeps  them  from 
leaving  the  house  or  occupying  themselves  with  ordinary  affairs.  A 
disconsolate  inactivity  and  weakness  of  will  and  imitative  force  ren- 
der life  1)itter  and  unbearable  for  such  patients.  Their  constant 
brooding  makes  them  inaccessible  to  beneficial  diversions,  and  pi'O- 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUIIOSES.        463 

duces  thereby  the  most  favorable  condition  for  the  constant  return 
of  their  imiDcrative  ideas. 

The  terminal  conditions  of  mental  torpor  must  not  be  con- 
founded with  dementia.  Termination  in  dementia  has  never  yet 
been  observed.^ 

The  following  points  may  be  mentioned,  explaining  functionally 
this  interesting  mental  disturbance : — 

1.  An  abnormally  intensified  impressionability  of  the  ideational  mental 
life,  with  immediate  establishment  of  relation  between  the  perception  or  mem- 
ory and  the  ego  (as  in  paranoia),  with  extremely  lively  emotional  coloring  of 
the  idea. 

2.  Intensified  activity  of  the  imagination,  which  allows  the  most  distant 
ideational  possibilities  to  develop  out  of  the  concrete  imperative  idea,  and 
which,  on  account  of  connection  with  widely  separated  circles  of  ideas  and 
situations,  constantly  excites  the  imperative  conception.'- 

3.  The  energy  of  thought  and  will  (activity  of  the  forebrain)  in  opposing 
the  imperative  ideas  by  voluntarily  calling  up  contrary  conceptions  in  these 
neuropaths  is  profoundly  reduced  (irritable  weakness). 

The  treatment  of  this  malady  must  consider,  in  the  first  place, 
the  neurotic,  neurasthenic,  physical  foundation.  The  most  important 
thing  is  to  strengthen  the  nervous  system  by  cold  water  and  climatic 
cures,  sea-bathing,  general  faradization,  and  by  the  use  of  tonics 
(iron,  quinine,  ergotine,  arsenic) ;  and  these  measures  even  in  pro- 
foundly constitutional  cases  produce  temporary  results. 

For  this  state  of  mental  suffering  the  most  important  beneficial 
influences  are  found  in  society,  travel,  distractions,  and  occupation, 
in  accord  with  the  patient's  taste,  which  must  not  be  too  taxing 
upon  the  feelings  nor  too  much  of  a  strain  mentally  and  physically. 
The  abnormal  impressionability  of  the  psychic  organ  may  also  be 
reduced  by  bromides  (from  4  to  6  grams),  as  well  as  by  amyl  hydrate 
in  prolonged  administration.  These  often  prevent  or  at  least  modify 
and  make  more  bearable  the  paroxysms,  especially  those  which  occur 
at  the  time  of  the  menses.  During  the  attacks  large  doses  of  bro- 
mides (from  6  to  10  grams),  injections  of  morphine,  chloral  hydrate, 
alcohol,  and  especially  the  comforting  encouragement  of  friends,  and 


^  Berger  observed  absolute  integrity  of  intelligence  in  one  patient  after 
twenty  years,  and  Kelp  after  thirty-eight  years. 

^  For  example,  a  patient  of  Sander  was  troubled  with  the  imperatiA^e  idea, 
at  the  sight  of  any  man,  that  she  had  been  intimate  with  him;  a  patient  of 
Berger,  who  had  the  imperative  idea  at  the  sight  of  boxes  that  there  was 
poison  in  them,  and  that  they  would  bring  harm  to  some  one,  and  that  she 
herself  was  guilty. 


464  SPECIAL  TATIIOLOGY  AXD  THERAPY  OF  INSANITY. 

assurances  about  the  actual  facts  from  some  person  in  the  patient's 
confidence  have  an  especially  quieting  influence. 

Case  41. — Insanity  due  to  imperative  ideas. 

Mr.  V.  C,  banker,  aged  52;  father  was  nervous,  sickly;  mother  weak 
nervously.  He  says  that  he  has  always  been  of  nervous  constitution,  always 
very  irritable,  sensitive,  impressionable,  as  were  all  his  brothers  and  sisters. 
At  the  age  of  17  he  lost  his  parents,  and  at  the  age  of  18  he  took  upon  himself 
a  large  business  and  the  care  of  his  brothers  and  sisters.  Of  great  rectitude 
and  rare  conscientiousness  to  the  extent  of  extreme  scruple  and  pedantry,  he 
amassed  a  great  fortune,  and  gained  the  highest  respect  of  the  community. 
He  lived  very  moderately,  but  was,  however,  an  inveterate  smoker.  He  never 
acquired  lues,  and  since  his  tAventy-seventh  year  he  had  lived  in  happy  mar- 
riage, though  he  was  under  extreme  strain  and  very  active  until  1880.  With 
the  exception  of  slight  indications  of  cerebrasthenia,  he  had  always  been  well. 

In  the  beginning  of  1880,  after  business  strain  and  violent  excitement,  he 
became  cerebrasthenic  (sleeplessness,  pressure  in  the  head,  difficulty  in  think- 
ing, loss  of  appetite,  emotionality).  In  August,  1880,  he  had  two  epileptiform 
attacks  near  together,  with  convulsions  especially  on  the  right  side  of  the 
body.  At  that  time  he  lay  some  days  in  coma  with  right-sided  hemiplegia, 
but  he  recovered  and  thereafter  presented  no  symptoms  of  organic  brain  dis- 
ease.    Toward  the  end  of  1880  liis  brother  died.     His  cerebrasthenia  increased. 

The  patient  continued  his  business  strain  and  remained  capable  of  work 
until  the  beginning  of  1884.  At  that  time,  one  day  as  he  was  looking  over  an 
account  the  thouglit  struck  him  that  the  account  was  not  correct  and  that  he 
had  made  a  mistake  to  the  disadvantage  of  a  customer.  He  was  forced  to  go 
over  the  accovmt  again  and  again,  but  could  not  find  any  satisfaction.  Then 
the  thought  came  that  former  accounts  were  incorrect.  This  thought  left  him 
no  rest,  and  he  was  forced  to  go  over  his  books  and  accounts  of  the  last  thirty 
years.  The  jjatient  thinks  himself  that  this  immense  mental  strain  has  quite 
finished  him.  He  put  no  more  trust  in  himself  to  work  alone,  for  fear  of 
making  errors  in  accounts  and  injuring  others.  With  that  there  was  the  fear 
that  he  might  compromise  himself  in  writing  or  speaking,  as  a  result  of  which 
he  could  scarcely  bring  himself  to  Avrite  or  speak.  Whenever  he  saw  a  bit 
of  paper  he  had  the  painful  thought  that  it  had  some  relation  to  him.  He 
became  restless,  con^anth'  troubled  with  doubts  as  to  whether  he  took 
proper  care  of  his  business,  or  Avhether  he  wrote  addresses  and  letters  cor- 
rectly, counted  money  correctly,  or  had  written  his  accounts  as  they  should  be. 
Finally,  he  had  no  trust  in  himself  except  in  the  presence  of  other  persons  who 
could  verify  what  he  did,  his  acts,  and  his  aflfairs.  When  he  prayed  he  was  no 
longer  satisfied  with  verbal  absolution;  it  had  to  be  written.  This  otherwise 
painful  situation  was  rendered  desperate  when,  after  a  few  months,  the  idea 
arose  that  he  might  harm  others.  This  threw  him  into  violent  excitement  and 
attacks  of  anxiety,  so  that  he  could  no  longer  see  his  children;  and  he  thought 
that  every  spot  or  bit  of  dust  or  a  bit  of  glass  or  a  needle  was  a  poison  which 
might  cause  harm  to  others.  His  fear  forced  him  to  wash  the  whole  day,  to 
examine  his  clothes  and  other  things,  and  to  undress  himself  frequently  in 
order  to  hunt  for  needles,  slivers,  etc.  Knally  he  had  no  rest  at  all  unless  his 
wife  (pro  -forma)  did  the  same  thing.  Hours  and  days  at  a  time  this  un- 
fortunate patient  had  no  respite  from  his  imperative  thinking.     At  times  he 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        465 

was  quiet,  comforted,  and  had  full  insight  into  his  disease.  On  June  6,  1885, 
the  patient  was  brought  to  me  by  his  relatives. 

The  patient  is  of  middle  size,  of  powerful  build,  but  much  reduced  in 
general  health.  The  vegetative  organs  are  normal.  The  most  careful  exam- 
ination shows  no  sign  of  organic  brain  disease.  Signs  of  degeneration  are  not 
present.  There  are  no  evidences  of  mental  weakness  or  melancholia.  The 
patient  gives  a  clear  r6sum4  of  his  disease  up  to  the  present  time,  and  at  times 
is  completely  master  of  his  imperative  ideas,  and  calls  attention  to  the  fact 
that  his  scrupulosity  is  painful  to  him,  as  well  as  his  association  of  ideas, 
which  brings  into  his  mind  the  most  distant  possibilities.  He  understands 
that  it  is  disease,  but  he  cannot  overcome  it.  He  is  under  the  domina- 
tion of  an  impulse  which  he  cannot  overcome.  Wlien  he  tries  to  do  this, 
he  is  terribly  distressed  and  becomes  excited.  He  is  tortured  from  morn- 
ing till  night.  His  depression  is  only  reactionary.  "Doubt  concerning  no 
matter  Avhat,  the  fear  of  causing  injury  to  another  by  no  matter  what  means: 
that  is  the  nualeus  of  my  disease." 

Physically  I  discovered  signs  of  cerebrasthenia  (pressure  in  the  head, 
unrefreshing  sleep,  complaint  of  general  fatigue,  lassitude,  and  great  emotion- 
ality). 

The  patient  complains  that  he  is  in  constant  anxiety  and  restless  while 
speaking,  for  fear  of  saying  some  untruth  or  of  compromising  others.  While 
eating  he  is  forced  to  examine  his  food  in  order  to  find  out  whether  there  are 
any  pieces  of  glass  or  needles  in  it.  This  fear  came  upon  him  some  months 
before  when  at  table  he  saw  a  broken  glass.  He  is  not  concerned  about  his 
life,  only  about  the  lives  of  others.  When  he  sees  a  funeral  procession  he 
fears  that  he  was  responsible  for  the  death  of  the  individual.  When  walk- 
ing he  is  troubled  by  the  idea  that  he  may  sow  needles  and  glass  splinters 
and- poison  about  and  thus  injure  others;  and  for  this  reason  he  cannot  be 
alone  a  moment,  and  must  be  constantly  assured  that  he  is  deceiving  him- 
self. His  own  judgment  and  evidence  of  his  senses  are  worth  nothing  to  him. 
To  his  excited  imagination  every  spot,  kernel,  bit  of  dust  or  thread  seems  to 
him  to  be  something  dangerous.  A  short  time  before  on  a  journey  from  the 
East  to  his  home  in  Europe  he  had  had  a  small  bottle  of  medicine  in  his  hands 
and  emptied  it.  Suddenly  the  fear  came  to  him  that  it  was  poison  and  that 
he  had  unconsciously  got  it  on  his  person.  From  this  time  on  there  was  fear 
of  poisoning  and  touching,  constant,  impulse  to  wash,  and  need  to  be  enlight- 
ened by  pharmacists  and  physicians  about  poison,  and  to  be  reassured  about 
the  contents  of  the  bottle.  On  the  journey  to  Europe  he  was  troubled  by  the 
thought  that  at  home  he  had  killed  everybody  by  this  supposed  poison.  He 
was  almost  in  despair. 

In  spite  of  all  his  washing,  he  still  feared  to  injure  others  present  by  the 
poison  on  his  hands.  Every  spot  on  the  furniture  or  on  his  clothing  seemed 
to  him  to  be  poison.  A  short  time  ago,  as  he  Avas  passing  by  the  window  of  a 
subterranean  passage  in  a  railway  station,  he  threw  in  a  piece  of  one  of  his 
finger-nails.  Immediately  the  thoLight  came  to  him  that  the  nail  was  poison 
and  would  be  dangerous  for  the  people  passing  through  the  passage.  He 
looked  down  for  an  hour  through  the  Avindow,  fearing  misfortune,  and  it  was 
only  with  great  difficulty  that  those  with  him  could  drag  him  away.  These 
thoughts  of  poisoning  were  fed  by  the  fact  that  the  patient  found  some  metal- 
lic shining  dust^  probably  from  a  lead-pencil,  in  one  of  his  waistcoat  pockets. 

so 


466  SPECL.iL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

This  was  clearly  metal.  While  eating  salad,  he  had  gotten  vinegar  on  his 
hands,  and  since  he  had  had  the  metal  between  his  fingers,  naturally  this  pro- 
duced soluble  metallic  salts.  In  tliis  way  he  spread  death  and  destruction 
around  liim. 

It  is  difficult  by  persuasion  and  written  assurance  of  experts  to  quiet 
the  patient.  He  is  also  tortured  by  the  idea  of  spreading  an  animal  poison 
about  with  his  toothpick  (from  the  bits  of  meat  sticking  to  it  having  under- 
gone decomposition).  The  patient  examines  the  glasses  anxiously  during 
meals,  to  be  sure  that  a  bit  of  glass  has  not  fallen  off  and  into  the  food. 

A  short  time  ago  he  saw  in  the  swimming  bath  a  boy  go  under  the  water 
near  by.  Immediately  he  feared  that  he  had  walked  on  this  boy  and  rendered 
him  unconscious,  and  that  the  boy  was  drowned.  The  patient  begs  that  the 
basin  be  em]itied,  fears  being  accused  of  committing  homicide  by  accident,  and 
is  inconsolable. 

The  patient's  friends  are  sorely  tried  by  him.  He  demands  that  he  be 
watched  constantly,  that  his  clothes  and  pockets  be  examined,  and  that  the 
floor  and  furniture  be  searched  for  poisons,  needles,  and  bits  of  glass.  He  is 
occupied  continually  with  scruples  and  cares,  and  demands  explanations  and 
reassurance.  Scarcely  is  this  accomplished  when  his  questions,  doubts, 
thoughts,  and  washings  begin  again. 

The  treatment  consists  in  combating  the  neurasthenia  ^\•ith  half-baths, 
rubbing,  and  electric  massage.  The  aqueous  extract  of  opium  up  to  0.5  gram 
a  day  in  connection  with  quinine  is  tried  for  the  psychic  hyperesthesia.  In 
severe  nervous  crises  the  bromides  are  found  useful.  Lloral  treatment  by 
patient  reassurance,  careful  explanations,  methodic  distraction,  and  strict  ob- 
servance of  a  plan  for  the  day  is  the  most  important. 

The  patient  becomes  quieter,  freer,  and  is  able  to  emjiloy  himself.  Now 
and  then  there  are  new  doubts;  for  example,  in  writing  letters,  that  there 
is  sulphuric  or  nitric  acid  in  the  ink  which  in  contact  with  the  steel  pens 
might  give  rise  to  substances  injurious  to  persons  to  whom  the  letters  are 
addressed,  and  thus  his  letters  would  be  dangerous.  On  anotlier  occasion  he 
thought  he  had  lost  a  needle  in  bed.  Clearly  the  needle  had  become  imbedded 
in  the  mattress.  Some  innocent  guest  would  be  in  danger  of  this  supposed 
needle,  which  might  penetrate  his  neck  and  cause  his  deatli.  The  patient 
exhausts  himself  in  such  possibilities  and  fears  and  constantly  asks  the  phy- 
sician how  death  occurs,  etc.  In  the  course  of  August  neurasthenic  symptoms 
pass  away.  The  patient  is  able  to  control  his  ideas  more  and  more,  and  the 
simple  reassurance  that  it  is  nothing,  or  that  it  is  nonsense,  is  sufficient  to 
calm  him.     Finally  he  trusts  himself  alone  in  a  room. 

Homesickness  makes  it  necessary  to  discharge  the  patient  in  October. 
For  a  long  time  at  home  he  did  well,  and  then  the  painful  state  of  this  pitiable 
patient  returned.     Apoplexy  brought  his  disease  to  an  end. 

(b)  Neiirasthoiic  Paranoia. 

This  clinical  form  of  paranoia  differs  from  the  t3^pic  form  in  that 
the  delusions  of  the  patient  are  nothing  less  than  a  false,  illogical 
interpretation  of  sensations  and  feelings  belonging  to  the  neuras- 
thenic neurosis,  by  a  consciousness  that  has  become  altered  in  the 
sense  of  paranoia.    The  patient  interprets  these  as  due  to  influences 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        467 

from  without;,  and  considers  the  pressure  in  his  head  as  the  efforts 
of  enemies  to  benumb  him  by  means  of  poisonous  emanations;  his 
disturbed  thought  as  the  result  of  machination  of  enemies,  who  wish 
to  destroy  his  reason  and  send  him  to  an  asylum.  His  dyspeptic 
sufferings  are  the  results  of  attempts  to  poison  liim.  His  numerous 
sensory  symptoms  (spinal  irritation,  paralgias,  muscular  and  cuta- 
neous hyperesthesias)  are  interpreted  in  a  physico-chemie  sense. 
Thus,  he  is  robbed  of  his  vital  power,  and  he  is  weak,  miserable,  etc. 

The  further  elaboration  of  the  delusional  system  is  helped  by 
errors  of  the  senses,  as  in  other  forms  of  paranoia.  The  clinical  con- 
tent is  specially  rich  when  the  point  of  departure  of  the  neurosis  is 
in  the  sexual  nervous  system,  whether  as  a  result  of  abuse,  especially 
onanism,  or  as  a  result  of  abstinence  with  intense  libido  (see  page 
187),  and  also  in  women  as  the  result  of  irritative  genital  diseases, 
which  lead  to  sexual  neurasthenia  ('lumbar  neurosis").  * 

In  this  same  manner,  also,  many  cases  of  paranoia  develop  during 
the  climacteric.  When  the  basis  is  sexual  neurasthenia,  and  it  occurs 
in  the  female  sex,  manifestations  of  an  hysteric  neurosis  are  seldom 
wanting;  and  these  likewise  offer  material  for  the  elaboration  of  the 
paranoiac  system  of  delusions.  Thus  there  are  clinical  transitions  to 
the  related  form  of  hysteric  paranoia.  The  jjure  neurasthenic  form 
develops  always  out  of  a  preceding  neurotic  state,  with  marked  noso- 
phobic  coloring,  which  passes  directly  into  delusions  of  observation 
and  persecution. 

The  most  striking  picture  upon  a  neurasthenic  basis  is  that 
which  develops  out  of  sexual  neurasthenia.  It  is  practically  almost 
the  same  thing  as  paranoia  masturbatoria. 

Paranoia  (SexualisJ  Masturbatoria. 

The  stage  of  incubation  presents  symptoms  of  neurasthenia 
sexualis  which  become  general.  The  nosophobic  ideas  are  about 
threatened  tabes,  insanity,  and  brain  softening.  In  its  course  delu- 
sions of  physical  persecution,  hallucinations  of  smell,  and  attacks  of 
apprehension  are  characteristic. 

The  beginning  of  paranoia  masturbatoria  is  usually  unnoticed. 
The  mental  uncertainty  in  social  intercourse,  and  the  painful  feeling 
that  everyone  sees  in  the  patient  his  secret  vice,  which  is  peculiar  to 
onanists,  aid  in  the  outbreak  of  the  disease.  The  patient  feels  and  be- 
lieves that  he  is  actually  watched,  observed,  and  soon  also  looked  at 
askance  and  persecuted.  Everything  has  a  relation  to  himself:  the 
conversation,  manner  of  people,  as  well  as  the  newspapers  and  adver- 
tisements, contain  evil  allusions  and  insults.    With  this  the  psychic 


468  SPECIAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

uncertainty  and  mistrust  increase.  Auditory  and  visual  illusions 
offer  further  food  to  the  developing  delusion.  Not  infrequently,  even 
at  the  beginning,  hallucinations  of  smell  of  a  disagreeable  kind  are 
interpreted  as  indicating  that  the  patient  gives  forth  a  foul  odor, 
and  that  he  is  regarded  as  being  afflicted  with  a  terrible  disease;  and 
thus  he  explains  the  supposed  aversion  of  people,  their  disgusted 
manner,  etc. 

After  months  or  years  of  incubation  the  heigiiL  of  the  disease 
is  reached  gradually  or  suddenly.  It  is  essentially  voices  of  a  perse- 
cutory character  which  induce  it.  The  patient  hears  voices :  lie  is 
a  nasty  fellow;  he  must  be  put  out  of  the  world;  a  society  has  sworn 
to  put  him  out  of  the  way.  The  delusions  of  persecution  have  abun- 
dant nourishment  in  the  numerous  neurasthenic  sensations  of  the 
patient.  Dyspeptic  symptoms  after  eating  are  taken  to  be  the  result 
^of  efforts  at  poisoning;  feelings  of  mental  inhibition  the  patient  in- 
terprets as  the  efforts  of  enemies  to  rob  him  of  his  reason  and  send 
liim  to  an  asyhmi.  Feelings  of  dullness  and  head-pressure,  due  to 
vasomotor  disturbance,  are  similarly  interpreted,  or  are  regarded, 
in  connection  with  hallucinations  of  smell  (chloroform,  prussic  acid, 
etc.),  as  the  result  of  hostile  design.  He  thinks  there  is  an  effort 
made  to  render  him  unconscious  in  order  to  rob  him  or  look  through 
his  effects,  or  to  put  compromising  things  among  them,  etc. 

The  neuralgic-paralgic  sensations  are  especially  important  as 
eccentric  symptoms  of  the  functional  overstimulation  of  the  sensory 
spinal  paths  due  to  onanism.  The  hyperesthesia  in  time  affects  also 
the  sensory  and  sensorial  territories.  Every  sensation  now  awakes 
a  corresponding  delirious  idea,  and  every  thought  arouses  a  corre- 
sponding sensation.  The  hyperesthetic  sense-organs  are  inclined  to 
hallucination  at  the  slightest  stimulus.  The  illogical  inte7-pre- 
tation  of  the  patient  finds  rich  material  in  the  anomalies  of  sensa- 
tion in  the  skin,  the  muscles,  or  in  general  sensibility.  Feelings  of 
weight,  of  stiffness,  of  lightness,  of  being  light  enough  to  fly,  of  emp- 
tiness or  of  heaviness  of  organs,  of  separation  of  the  soul  from  the 
body,  of  magnetic  streams,  occur  and  induce  motor  reflexes  which 
may  go  to  the  degree  of  local  and  general  spasm  (catatonia),  and  they 
force  the  patient  to  seek  for  explanations. 

The  uniformity  with  which  these  anomalies  of  sensation  ai'e 
interpreted  is  astonishing.  In  educated  patients  they  think  them- 
selves influenced  by  means  of  secret  magnetic  and  electric  machines 
worked  by  enemies.  Uneducated  patients  interpret  them  as  persecu- 
tion with  "sympathy,'^  witchcraft,  poisonous  emanations,  or  as  the 
result  of  having  poison  thrown  over  them,  etc. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        4 GO 

Not  infrequently  local  neuroses  of  the  genitals  are  interpreted 
in  tliis  sense  (irritable  testis,  hypersesthesia  urethra3,  neuralgia  sper- 
matica).  The  enemy  practices  onanism  with  the  patient,  causes 
pollutions,  etc. 

The  disease  is  subject  to  remissions  and  exacerbations,  the  latter 
usually  associated  with  renewed  onanistic  excesses,  and  occurring  with 
increased  hallucinations,  sensations,  and  increased  spinal  reflex  ex- 
citability, which  may  go  to  the  degree  of  tonic  and  clonic,  or  catalepti- 
f orm  or  epileptiform  attacks,  due  to  reflex  action  upon  the  vasomotor 
areas.  The  further  course  is  like  that  in  the  other  forms  of  typic 
acquired  paranoia. 

aSTot  infrequently  there  is  transformation  to  delusions  of  gran- 
deur. States  of  mental  weakness  occur  earlier  and  are  more  pro- 
nounced in  paranoia  upon  this  basis  than  in  the  other  etiologic 
varieties  of  the  disease.  The  manifestations  of  neurasthenia  and 
spinal  irritation  are  amenable  to  tonic  treatment  (hydrotherapy, 
etc.).  Morphine  and  bromides  reduce  the  hyperesthesias,  paralgias, 
and  hallucinations,  and,  at  any  rate,  are  not  without  value  sj^mp- 
tomatically. 

Case  42. — Paranoia  masturbatoria. 

D.,  engineer,  aged  38,  single ;  parents  tuberculous.  One  sister  is  neuro- 
pathic, another  is  insane.  Patient  was  an  onanist  from  his  early  youth  until 
the  age  of  thirty-six,  though  he  was  healthy  and  industrious  in  his  calling. 
At  that  age  he  began  to  be  ailing:  losing  flesh,  suspicion  of  lung  trouble,  neu- 
rasthenic symptoms.  A  climatic  cure  improved  his  condition  very  much. 
Soon  after  returning  to  his  occupation  neurasthenic  troubles  became  more 
frequent,  with  neuralgia  testis  and  gastric  trouble  with  obstinate  vomiting. 
The  patient  became  profoundly  hypochondriac,  thought  himself  impotent,  and 
made  self-accusations  on  account  of '  his  onanism.  He  had  doubts  of  his 
recovery,  and  became  shy  and  irritable. 

In  the  further  course  numerous  sensations  make  their  appearance.  He 
feels  an  electric  fire  in  his  body.  From  his  left  foot  a  current  enters  his  body. 
His  bed  is  insulated.  He  feels  that  his  body  is  divided  into  two  halves. 
When  he  gets  out  of  a  carriage  he  has  the  feeling  as  if  his  body  had  been 
left  behind  in  an  airy  state.  With  this  there  is  pressvire  in  the  head,  buzzing 
in  the  ears,  and  persistent  sleeplessness.  Once  he  hears  a  voice:  "I  have 
made  you  electrically  positive  and  negative."  When  on  a  business  trip  he  sud- 
denly has  a  feeling  as  if  the  food  has  slipped  out  of  his  mouth  into  his  left 
foot.  At  night  he  hears  a  voice,  "How  wonld  you  like  to  die,"  and  believes 
that  his  last  hour  has  come.  His  dead  parents  and  family  physician  appear  to 
him.  Another  time,  on  going  to  bed,  he  sees  around  him  unknown  forms  in  a 
red  haze.  He  hears  imperative  voices  which  say  to  him  he  must  pray  and  go 
to  the  pharmacy  and  get  musk.  Lying  on  the  sofa,  he  hears  it  said  that  it  is 
a  dissecting  table.  In  the  street  he  is  called  hypocrite,  liar,  etc.  In  bed  at 
night  he  often  has  the  feeling  as  if  his  hands  and  feet  were  burned  and  his 


470  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

penis  pulled  out.  He  feels  as  if  he  vrere  being  dissected  and  tissue  being  pulled 
out  of  his  body,  as  if  objects  were  being  i)ushed  into  various  parts  of  his  body, 
or  as  if  his  bones  were  being  torn  out.  He  feels  that  he  is  magnetized  and  his 
heaü  metallic. 

Increasing  excitement  as  a  result  of  these  dreadful  and  numerous  errors  of 
the  senses,  after  tAvo  years'  duration  of  the  disease,  made  it  necessary  to  place 
him  in  ah  insane  asylum.  The  trouble  continued  to  progress.  He  is  magnet- 
ized, electrified,  no  longer  has  any  intestines.  The  physicians  make  electric 
streaks  on  his  abdomen.  He  feels  an  elephant's  trunk  on  his  back.  Food 
falls  into  the  scrotum.  A  chain  is  sawing  him.  He  is  being  bored  in  the 
navel.  Pointed  bodies  are  being  driven  into  him  on  all  sides.  The  bed  sways. 
Machines  and  knives  are  stuck  into  his  abdomen.  He  has  a  mass  of  iron 
angles  in  his  abdomen,  and  teeth  have  penetrated  it. 

At  the  same  time  the  patient  is  subject  to  numerous  halhu'inations  of 
hearing.  At  the  window  he  hears  the  cocks  crowing.  He  hears  that  he  is 
incurable  and  will  be  dissected;  that  he  is  the  Wandering  Jew  and  has  shot 
the  attending  physician's  wife.  The  bells  and  flies  speak  to  him.  His  own 
thoughts  and  obscenities  are  spoken  to  him.  He  is  called  a  bloodhound,  and  in 
the  stroke  of  the  bell  he  hears  his  own  name.  The  final  syllable  Yieh  (beast) 
is  attached  to  all  his  words.  He  receives  command  to  box  the  ears  of  all  those 
aroimd  him.  The  clock  tells  him  that  he  is  a  bankrupt.  Everywhere  he  hears 
words  of  contempt;  such  words  come  to  him  from  the  sun.  Clearly  telegraphic 
influences  are  in  play.     He  hears  human  excrement  fall  from  the  ceiling. 

In  the  course  of  the  disease  there  are  hallucinations  of  sight.  He  sees 
everything  in  spirit,  even  the  inside  of  his  body.  He  sees  his  name  in  the  air. 
Everything  in  the  room  is  transparent.  He  sees  the  butterflies  in  a  collection 
fly  away  before  his  eyes.  When  he  tries  to  read,  the  letters  fly  out  of  the 
window.  Frequently  the  visions  also  have  an  obscene  character.  He  sees 
genitals  flying  about  and  obscene  pictures  on  the  walls.  In  his  coffee  on  one 
occasion  he  saw  a  beautiful  girl  who  beckoned  to  him. 

The  hallucinations  of  taste  and  smell  are  of  subordinate  significance.  At 
times  he  has  a  metallic  taste  in  his  mouth,  especially  when  he  feels  in  it  mag- 
netic currents.  Now  and  then  the  food  has  a  poisonous  taste,  and  he  smells 
persons  that  have  been  executed. 

The  patient  practices  onanism  very  excessively.  After  frequent  onanistic 
excesses  his  sensory  excitability  is  so  intense  that  he  has  visions  whenever  he 
closes  his  eyelids.  One  day  in  a  court  a  coat  was  being  dusted.  He  suddenly 
felt  that  he  was  thought  of,  and  immediately  that  he  Avas  being  whipped  and 
that  the  blows  hurt  him.  At  the  time  of  great  excesses,  disturbances  of  gen- 
eral sensibility  and  the  delusion  of  electro-magnetism  are  livelier  and  come  into 
the  foreground.  He  then  feels  the  drawing  and  repulsion  of  positive  and  nega- 
tive electricity,  as  if  he  were  touched  with  magnetic  wires.  He  is  read  through 
and  has  the  feeling  as  if  he  were  cut  with  a  knife.  Lungs,  brain,  and  memory 
are  in  a  telegraphic  way  removed  from  him  and  from  the  asylum  and  sold  to 
others.  These  abnormal  feelings  and  perceptions  are,  in  part,  laid  to  those 
around  him  and  lead  to  acts  of  violence;  in  part,  without  any  reflection.  In 
time  the  intensity  of  the  read  inn  diminishes,  and  they  become,  in  a  measure, 
less  frequent.  The  general  course  of  this  brain  disease,  manifesting  itself 
essentially  in  hallucinations,  was  over  twelve  years.  Up  to  his  latest  years  he 
was  given  to  onanism,  and  died  of  pulmonary  tuberculosis. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        471 

Case  43. — Paranoia  upon  the  foundation  of  sexual  neurasthenia 
in  the  climacteric. 

Mrs.  W.,  aged  .50,  adjniLted  September  8,  1880.  Her  ancestry  is  unknown. 
Always  neuroi^athic,  irritable,  impossible,  peculiar.  Separated  from  her  hus- 
band seventeen  years.  At  the  time  of  the  menses  always  depressed  and 
troubled  with  migraine.  Mother  of  foTir  children.  The  climacteric  began  in 
the  summer  of  187!)  (profuse,  irregular  menses;  frequent  cerebral  congestion; 
increased  irritability;  more  frequent  attacks  of  migi-aine;  troublesome  draw- 
ing in  the  back  and  legs,  and  cold  chills  over  the  body).  In  the  course  of  the 
winter  of  1879  and  1880  she  complained  of  spinal  irritation,  pressure  in  the 
head,  and  felt  dull,  restless,  and  did  not  like  to  leave  the  house.  In  February, 
1880,  she  became  suspicious,  felt  that  she  was  watched  and  observed,  and 
thought  the  police  were  after  her.  She  thought  that  her  son,  who  wished  to 
make  a  marriage  against  his  mother's  will,  with  the  young  lady  was  making 
attempts  against  her  life.  Dyspeptic  troubles,  pressure  in  the  head,  and  head- 
ache after  meals  she  interpreted  as  attempts  to  poison  her.  She  thought  she 
smelled  the  poison.  This  made  her  weak  and  gave  her  fever.  Her  tongue  was 
as  if  covered  with  white  lead.  Calomel  was  put  in  mineral  water,  which 
regularly  gave  her  diarrhea  and  meteorism.  Since  she  could  not  bear  it  any 
longer,  she  went  from  Gratz  to  Vienna  and  Salzburg,  but  found  rest  nowhere. 
Wherever  she  went  she  was  the  object  of  observation.  At  times  she  perceived 
a  suflocating  odor  of  cannel.  Her  abdomen  had  been  made  to  swell  up  with 
water  containing  hydrosulphuric  acid,  and  her  food  was  poisoned  with  arsenic. 

Of  late  the  patient  was  threatening  and  hostile  to  those  around  her,  and 
this  had  necessitated  her  commitment.  Neuropathic  habitus.  The  left  side 
of  her  face  is  less  developed  than  the  right.  Ears  abnormally  large.  Dorsal 
vertebra  sensitive  to  pressure.  Vegetative  organs  normal.  Examination  of 
the  uterus  was  not  permitted. 

The  patient  is  constantly  s^ispicious  and  irritated.  She  will  not  stay  in 
bed  because  the  iron  bedstead  and  the  pillow  she  suspects  of  conducting  elec- 
tiicity  and  giving  her  headache  and  vertigo.  Here  the  patient  believes  that 
she  is  persecuted  with  spirits  and  electricity,  and  she  writes  many  protests  on 
account  of  her  commitment,  and  asks  the  court  to  release  her.'  Her  enemies 
(son  and  the  young  lady)  have  corrupted  the  Professor  of  Physics.  The  latter 
exercises  constantly  upon  her  influences  by  means  of  sunglasses  and  machines. 
She  is  the  "medium"  for  the  whole  city  of  Gratz.  She  is  watched  through 
tubes.  She  feels  this  in  both  ears.  They  give  her  a  whirlwind  in  her  brain, 
and  thus  all  her  thoughts  are  divulged.  Her  head  is  squeezed  in  a  vise,  and 
her  blood  is  forced  here  and  there.  The  nerves  of  her  head  are  stimulated  so 
that  she  has  to  bend  her  head  back.  This  is  done,  in  part,  with  a  concave 
mirror  which  induces  the  distant  effect  of  magnetism,  and,  in  part,  by  an  in- 
visible glass  bell  which  is  above  her  head.  With  the  exception  of  her  bladder, 
there  is  no  part  of  her  body  that  is  protected  from  the  distant  effects  of 
spiritualism. 

The  vertex  is  the  seat  of  a  burning,  turning  sensation.  The  glabella  is 
at  times  bored,  her  ears  pulled,  and  the  occiput  pressed.  The  temples  are 
taken  in  a  vise,  and  the  cheeks  alternately  filled  Avith  blood;  the  evelids 
pulled  up  to  the  brow  by  nerves.  The  tongue  is  affected  with  poison,  and  the 
nose  with  disgusting  odors.     Breathing  is  interfered  with  by  pressing,  drawin«' 


472  SPECIAL  PATHOLOGY  AND  THEKAPY  OF  INSANITY. 

feelings  in  the  chest,  and  the  heart's  action  is  made  irregular.  She  is  caused 
to  be  constipated  or  to  have  diarrhea.  Her  persecutors  keep  her  in  permanent 
excitement.  She  refuses  quieting  medicines,  taking  them  to  be  poison.  The 
condition  remains  stationary,  and  since  she  was  not  amenable  to  any  treat- 
ment she  was  given  over  to  a  hospital  for  the  chronic  insane. 


CHAPTER  II. 

Epileptic  Insanity. 

Clinical  Limitations  of  the  Epileptic  Keurosis.    Epileptic 

Character  and  Elementary  Mental 

Disturbances  of  Epileptics. 

The  clinical  notion  of  epilepsy  has  undergone  considerable  expansion 
since  the  days  of  Hippocrates.  To-day  nervous  pathology  is  acquainted,  with 
the  fact  that,  in  place  of  the  general  tonic  and  clonic  convulsion  with  loss  of 
consciousness,  there  may  be  nervous  attacks,  which  at  first  sight  seem  to  have 
little  or  nothing  in  common  with  the  classic  epileptic  attack,  but  which,  never- 
theless, must  be  recognized  as  signs  quite  as  characteristic  of  epilepsy.  The 
following  are  unquestioned  equivalents: — 

1.  Mere  interruptions  in  the  continuity  of  consciousness;  loss  or  mere 
clouding  of  consciousness  for  a  few  seconds  or  minutes  with  pallor  of  the  face 
(mental  absences  without  any  accompanying  motor  or  especially  convulsive 
disturbance). 

2.  The  same  defect  or  clouding  of  consciousness  associated  with  partial 
muscular  spasm.  These  may  be  limited  to  momentary  squinting,  grimacing, 
twisting  of  the  head  or  the  limbs,  or  stuttering  of  incoherent  words. 

3.  The  same  disturbance  of  consciousness  with  simultaneous  automatic, 
dreamy,  impulsive  acts;  for  example,  urinating,  collecting  objects  that  are 
near  at  hand,  running  blindly,  etc. 

According  to  Griesinger,  even  attacks  of  vertigo  which  mount  from  some 
peripheral  part  of  the  body  to  the  head,  thus  having  an  aura-like  character, 
and  which  are  attended  with  apprehension,  momentary  disturbance  of  con- 
sciousness, confusion  of  thought,  palpitation,  and  automatic  movements  of  the 
lips  or  of  swallowing,  may  have  the  significance  of  an  epileptic  attack;  the 
more  if  the  patient  runs  about  after  his  confused  dream,  saying  irrelevant 
things,  committing  senseless  acts,  etc.,  and  if  the  attacks  are  repeated. 

The  observations  of  Emminghaus  make  it  probable  that  paroxysmal 
sweating  occurring  without  cause,  and  especially  without  muscular  exertion, 
with  or  without  vertigo,  and  with  reduction  of  motor  innervation  and 
trembling,  are  to  be  interpreted  as  attacks  of  an  epileptic,  neurosis. 

This  is  also  true  of  the  peculiar  attacks  of  sleep  observed  by  Westphal 
and  Fischer  in  patients  suspected  of  epilepsy;  and  of  attacks,  observed  in  epi- 
leptics, of  neuralgia,  for  the  most  part  intercostal,  which  were  accompanied 
by  disturbance  of  consciousness  and  other  accompaniments  of  the  otherwise 
classic  convulsive  attack;  further,  of  frequently  repeated  attacks  of  fainting 
with  sudden  loss  and  sudden  return  of  consciousness;  and  finally  of  certain 
cases  of  nocturnal  fright  and  somnambulism  in  persons  who  later  presented 
epileptic  attacks. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        473 

This  enlargement  of  clinical  experience,  which  is  still  very  incomplete, 
makes  the  description  of  the  characteristic  marks  of  the  epileptic  attack  more 
and  more  difficult,  but  still  indispensable,  if  the  clinical  idea  of  epilepsy  is  not 
to  pass  away. 

The  epileptic  attack  is  undoubtedly  a  peculiar  manner  of  reaction  of  an 
abnormally  altered  brain,  and  at  the  same  time  a  symptom-complex  which  can 
never  be  resolved  into  a  single  symptom. 

•  In  great  part  the  clinical  picture  of  epilepsy  probably  depends  upon  the 
regional  radiation  of  the  cerebral  process  lying  at  the  foundation  of  the  epi- 
leptic attack;  as,  for  example,  vertigo  upon  vascular  spasm  of  the  cerebral 
hemispheres;  or  the  classic  attack  upon  the  spreading  of  the  process  to  the 
motor  cortical  fields  and  the  subcortical  centers. 

In  the  present  state  of  scientific  knowledge,  it  seems  justifiable  to  recog- 
nize at  least  the  absences  and  attacks  of  vertigo  as  manifestations  of  like 
value  with  the  ordinary  epileptic  attack,  and  the  other  paroxysmal  manifesta- 
tions which  occur  in  epileptics,  or  in  those  suspected  of  epilepsy,  as  epileptoid, 
until  it  is  possible  to  establish  them  as  equivalents  of  the  ordinary  attack. 

The  general  characteristics  of  the  epileptic  or  epileptoid  attacks  are: 
Repeated  occurrence,  in  one  or  another  of  the  forms  mentioned,  with  disturb- 
ance or  loss  of  consciousness  while  they  last,  of  sudden  symptoms  of  disturbed 
cerebral  circulation  due  to  vascular  spasm,  whether  these  consist  of  pallor  of 
the  face  or  of  the  fundi,  or  of  partial  or  general  spasmodic  motor  disturbances. 

In  any  event,  a  single  symptom  is  not  sufficient  to  establish  the  diagnosis 
of  epilepsy  nor  is  a  single  epileptic  attack.  But  we  are  not  hampered  in  prac- 
tice merely  by  the  incompleteness  of  our  knowledge  as  to  what  attacks  are  to 
be  regarded  as  epileptic,  as  well  as  by  the  protean  manner  of  the  manifesta- 
tions, but  also  by  the  difficulty  that  actual  epileptic  attacks  may  escape  ob- 
ser^'ation.  This  is  especially  true  of  slight  vertiginous  attacks  which  occur  at 
night.  In  such  patients  it  may  happen  that  neither  patient  nor  others  have 
any  suspicion  of  the  serious  nervous  disease  that  exists. 

At  least,  as  suspicious  symptoms  of  nocturnal  epilepsy,  we  may  regard 
occasional  and  repeated  wetting  of  the  bed,  falling  out  of  bed,  ecchymoses  of 
the  face  (especially  of  the  sclera),  injuries  of  the  tongue,  headache,  dullness 
and  confusion  of  thought,  and  lassitude  and  depression  on  waking. 

Great  diagnostic  significance  is  found  in  the  fact  that  the  epileptic  is  not 
merely  ill  during  his  attacks,  but  constantly  ailing,  chronically  nervous.  The 
attacks  are  only  especially  marked  symptoms  of  an  abnormal  condition  of  the 
central  nervous  system,  which  is  present  also  during  the  intervals.  This  con- 
dition may  be  hereditary  or  induced  by  injury  to  the  brain ;  and  this  makes  it 
clear  how  slight  exciting  causes,  like  fright,  may  bring  on  the  outbreak  of 
epilepsy.  Experimental  pathology  has  succeeded  in  inducing  this  abnormal 
cerebral  condition  (epileptic  change)  artificially  by  injury  of  the  spinal  cord  or 
peripheral  nerves  (Brown-Sequard) ;  by  cerebral  concussion  (Westphal)  ;  by 
injury  of  parts  of  the  cortex  (Hitzig).  It  also  shows  itself  in  a  functional 
intensification  of  cerebral  excitability,  especially  of  the  vasomotor  and  con- 
vulsive centers. 

As  an  expression  of  the  lasting  cerebral  change  in  epileptics  there  are 
numerous  symptoms  observable  during  the  intervals  which,  in  part,  show  the 
existence  of  an  abnormal  cerebral  condition  in  general,  and,  in  part,  as  a 
matter  of  experience,  indicate  the  existence  of  epilepsy,  and  which,  perhaps, 


474  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY.  "^ 

may  bring  into  relief,  from  a  diagnostic  standpoint,  doubtful  symptoms  of  an 
attack. 

As  marks  indicating  that  the  individual  is  all'ected  nervously  in  general, 
Ihoro  arc  symptoms  of  a  neuropathic  constitution, — irritable  weakness,  head- 
ache, vertigo,  intolerance  of  alcohol,  tremor,  occasional  twitchings,  muscular 
cramps  (especially  in  the  calves),  vasomotor  symptoms  (alternating  blushing 
and  pallor  of  the  face);    cold,  cyanotic  extremities;    nystagmus. 

As  indicating  the  existence  of  a  probable  epileptic  neurosis  there  are  cer- 
tain peculiarities  of  character  (so-called  epileptic  character),  wiiicli,  on  careful 
observation,  so  many  epileptics  present.  The  most  important  of  these  are  the 
abnormal  emotional  irritability  and  a  moody  character  which  alternates  be- 
tween exaltation,  with  abnormal  intensification  of  the  will,  and  mental  de- 
pression (moroseness,  hypochondriac  depression,  with  or.  without  imperative 
ideas,  mental  apathy,  dejection,  apprehension  that  may  become  anxiety  in 
connection  with  indifl'erent  acts,  depression,  and  apprchensiveness).  The 
character,  however,  is  especially  distrustful,  uncommunicative,  susceptible, 
peculiar,  incomprehensible,  obstinate,  self-willed  with  foolishness  in  sticking 
to  ideas;  so  that  the  individual  seems  incapable  of  accommodating  himself  to 
any  given  relation  and  appears  in  the  rule  of  a  household  tyrant,  misanthrope, 
or  uncompromising  friend. 

In  many  epileptics  there  is  also  an  element  of  bigotry  in  the  character: 
a  pathologic  religiosity,  a  hangdog,  hypocritic  nature,  Avhich,  in  accordance 
with  whether  the  patient  is  exalted  or  depressed,  expresses  itself  in  exaltation 
or  mortification.  This  bigotry  and  air  of  the  martyr  are  in  remarkable  con- 
trast with  the  irritability,  combativeness,  brutality,  and  moral  defect  of  "poor 
epileptics,  who,  with  a  prayer-book  in  the  pocket  and  the  word  of  God  on  the 
tongue,  have  the  most  extreme  wickedness  in  the  heart"  (Samt). 

Along  with  these  lasting  abnormalities,  partly  as  prodromes  of  the  on- 
coming epileptic  or  epileptoid  attack,  partly  following  the  attack,  there  are 
patliologic  symptoms,  the  diagnostic  importance  of  which  is  increased,  since 
they  frequently  occur  quite  typically  before  or  after  the  attacks. 

These  symptoms — which  precede  attacks  a  few  minutes,  hoiu-s,  or  days — 
have  oftentimes  the  character  of  an  aura.  Besides  ascending  sensations  from 
the  extremities  or  from  the  epigastriiun  to  the  head,  with  chilly  feelings  and 
dizziness,  in  the  psychic  and  sensorial  domain  there  are  frightful  hallucinations 
of  sight,  hearing,  and  sometimes  of  smell,  and  also  subjective  sensorial  impres- 
sions, like  roaring  in  the  ears,  photopsias,  and  chromatopsias,  especially  red 
flames  ' ;  precordial  distress  with  violent  impulses,  mental  depression,  intensifi- 
cation of  the  habitual  irritability,  formal  disturbances  of  thought  (confusion, 
difficult  thinking,  imperative  ideas) ;  a  clouding  of  consciousness  as  if  intoxi- 
cated. Sometimes  there  is  maniacal  gayety,  with  increased  activity  of  thought 
and  kleptomaniac  activity. 

As  mental  disturbances  following  immediately  upon  an  epileptic  attack, 
there  may  be  great  mental  prostration  with  inability  to  think,  with  profound 


^In  a  case  that  came  under  my  observation  the  sensorial  aura  each  time 
consisted  of  the  vision  of  a  man  with  a  red  mantle  and  beard.  The  patient 
then  became  sick.  He  saw  the  phantom  vomit.  Then  the  patient  vomited  and 
lost  his  senses. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        475 

confusion  and  disturbance  of  apperception  going  to  the  degree  of  stupor,  which 
may  last  from  half  an  hour  to  several  days.  With  this  there  may  be  great 
emotional  depression  with  excessive  irritability  and  raptus-like  impulses, 
which,  either  as  a  result  of  frightful  visions,  host^ile  apperception,  or  fear,  may 
lead  to  suicide,  murder,  or  arson. 

Kleptomaniac  impulses,  as  an  accompaniment  of  mania-like  states  of 
exaltation,  may  occur.  This  post-epileptic  stage  of  disturbance  of  conscious- 
ness and  psychic  pain,  as  a  rule,  soon  passes  away,  to  give  place  to  the  former 
state  of  mental  clearness. 

However,  as  a  result  of  repeated  epileptic  attacks,  it  happens  that  in  the 
intervals  between  attacks  a  peculiar  somnambulistic,  dreamy  state  of  con- 
sciousness exists  in  which  the  patient  seems  to  be  quite  himself,  speaks  con- 
nectedly, acts  naturally,  and  even  goes  about  his  afl'airs,  though,  however,  he 
is  not  himself:  i.e.,  not  in  possession  of  his  proper  self -consciousness,  so  that 
later  he  knows  nothing  of  what  he  has  done  while  in  tliis  condition.  This 
peculiar  epileptic  state  of  clouded  consciousness  may  last  several  hours. 

Epilepsy  is  not  merely  attended  by  elementary  psychic  disturb- 
ances; it  frequently  enough  leads  to  a  lasting  and  profound  deterio- 
ration of  the  mental  functions,  upon  which  foundation  acute  delirimn 
and  less  frequently  actual  psychoses,  partly  as  a  complication  of  the 
entire  neurosis,  partly  as  equivalents  of  epileptic  attacks,  may  make 
their  appearance. 

The  lasting  change  of  the  psychic  personality  may  be  called  epi- 
leptic psj^chic  degeneration;  the  transitory  syinptom-coniplex  is 
called  by  an  older  general  term  "epileptic  mania,"  although  it  has 
nothing  in  common  with  mania,  and  by  this  term  the  most  varied 
forms  of  mental  disturbance  are  designated— acute  mental  attacks 
which  have  not  yet  been  sufficiently  or  satisfactorily  studied. 

The  epileptic  jDsychoses — i.e.,  those  that  are  specific  and  occur 
only  in  epileptics — have  only  been  investigated  of  late  and  especially 
by  Samt.  They  have  many  points  of  contact  with  and  transitions  to 
certain  forms  of  periodic  insanity,  especially  with  those  that  consist 
in  attacks  of  short  duration. 

Epileptic  insanity  includes  psychopathic  states  that  are  partly 
lasting,  partly  transitory.    It  may  be  classified  as  follows : — 

1.  Epileptic  psychic  degeneration. 

2.  Transitory  and  usually  delirious  psychic  disturbances  of  epileptics. 

3.  Protracted  psychic  equivalent. 

4.  Epileptic  psychoses. 

1.  Epileptic  Psycliic  Degeneration. 

If  one  examines  the  mental  condition  of  a  large  number  of  epi- 
leptics, the  fact  is  brought  out  that  in  the  majority  of  them  the  in- 


476  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tegrit}'  of  the  psychic  functions  is  lastingly  disturbed.     The  follow- 
ing are  the  constant  signs  of  this  profound  mental  change : — 

1.  A  reduction  of  intellectual  power,  that  in  the  slighter  cases 
is  a  mere  weakness  of  reproduction,  apperception,  and  combination 
of  ideas,  which  expresses  itself  clinically  in  forgctfulness,  dilTiculty 
of  judgment  and  comprehension,  defective  apperception,  and  func- 
tional weakness  of  the  psychic  mechanism  in  general.  This  psychic 
weakness  may  be  observed  in  all  degrees,  from  feeble-mindedness  up 
to  complete  dementia. 

Sometimes  this  degenerative  manifestation  affects  especially  the 
ethic  side  of  the  individual,  and  expresses  itself  clinically  in  func- 
tional weakness  or  loss  of  ethic  and  esthetic  feeling  and  judgment, 
which  finds  its  practical  expression  in  brutality,  cruelty,  and  crim- 
inally immoral  conduct;  and  the  immoral  criminal  impulse  may  occur 
periodically  and  with  an  absolutely  impulsive  character. 

Sommer  has  closely  studied  this  post-epileptic  dementia.  In  the  first 
place,  the  temporary  dullness  of  intelligence  following  upon  tlie  epileptic  at- 
tacks becomes  more  and  more  prolonged.  Apperception  becomes  duller  and. 
increasing  intensity  of  stimuli  is  required  in  order  to  produce  pei-ceptions. 
With  this  there  is  forgetfulness:  first,  for  late  events,  then  gradually  the 
impressions  of  remoter  periods  are  destroyed.  Still,  during  a  long  period 
the  patient  feels  this  loss  and  tries  his  best  to  conceal  it.  In  general,  the 
patient  is  conscious  of  the  sad  condition  that  has  made  him  a  burden  to 
himself  and  others,  and,  according  to  Sommer,  this  explains  in  part  his 
tendency  to  lean  on  religion,  in  Avhich  he  seeks  comfort  in  liis  devotion  and 
unselfislmess  toward  others.  However,  these  religiovis  and  altruistic  tend- 
encies are  frequently  distorted  by  intense  egotism  and  great  irritability. 

2.  Excessive  irritability,  which  at  the  slightest  cause  explodes 
into  angr}^,  violent  affects,  and  may  go  to  the  extent  of  paroxysms 
of  rage. 

3.  Intensification  of  the  affective  disturbances  which  have  al- 
ready appeared  in  the  epileptic  character,  and  then  the  morose  humor 
and  the  contemptuous,  distrustful  appreciation  of  the  external  world 
take  more  and  more  the  upper  hand,  manifest  in  the  facial  expression, 
and  giving  to  the  patient's  physiognomy  a  sinister  look. 

4.  In  this  picture  of  degeneration  there  are  now  and  then  im- 
perative ideas,  primordial  delusions  of  persecution,  frightful  hallu- 
cinations, attacks  of  fear,  impulsive  acts,  which  are  partly  to  be 
regarded  as  aurge  of  unobserved  or  abortive  epileptic  attacks,  partly 
as  independent  elementary  psychic  disturbances. 

5.  In  many  cases  of  advanced  epilepsy,  or  in  cases  that  began  in  early 
years,  with  these  phenomena  of  psychic  decay  there  are  also  motor  disturb- 
ances which,  especially  in  cases  of  epilepsy  that  have  arisen  in  childhood,  fre- 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        477 

quently  present  the  character  of  marked  paralysis  of  hemiplegic  character, 
and  tend  to  become  complicated  with  contractures  and  secondai-y  muscular 
atrophies.  In  other  cases  we  observe  tremor,  nystagmus,  inequality  of  facial 
innervation,  choreiform  movements,  paralysis  of  the  tongue,  and  aphasic 
symptoms.  Sensory  disturbances  are  also  frequent  in  epileptic  degenei-ation. 
They  may  present  themselves  in  the  form  of  neuralgia  in  distinct  nerve-paths, 
or  as  general  hyperesthesia. 

In  the  final  stages  of  epileptic  degeneration  the  signs  of  psychic  deterio- 
ration are  accompanied  by  others  of  physical  decay.  The  features  take  on 
a  dull  expression,  the  subcutaneous  adipose  tissue  becomes  hypertrophic,  and 
the  features  thus  have  a  coarse,  plmnp  appearance,  and  the  lips  are  prominent. 

S.  Transitory  Aitaclcs  of  Psychic  Dislurhance. 

These  consist  of  disease-pictures  limited  and  sharply  defined, 
lasting  from  a  few  hours  to  a  few  days^  which  come  on  suddenly  and 
as  suddenly  disappear.  They  may  he  forerunners,  or  more  frequently 
the  result,  of  epileptic  attacks,  and  they  may  occur  immediately  after 
or  within  a  few  hours  or  days.  Sometimes,  but  infrequently,  they 
occur  in  epileptics  as  independent  attacks  in  the  interval.  They  are 
very  prone  to  occur  after  repeated  epileptic  attacks,  especially  when 
these  have  been  preceded  by  a  prolonged  period  of  freedom  from 
attacks.  Sometimes  it  happens  that  the  vertiginous  or, classic  epi- 
leptic attack  is  supplanted  by  these  psychic  attacks,  which  then  may 
be  regarded  as  equivalents.  There  are  authentic  cases  in  which  this 
equivalent  has  lasted  for  decades.  It  is  usual  to  call  such  cases 
larvated,  or  psychic,  epilepsy. 

Since  this  transformation  of  the  neurosis,  this  substitution  for  the  at- 
tack, occurs  with  especial  facility  in  cases  of  mere  vertiginous  epilepsy,  the 
original  picture  of  epilepsy  may  become  distorted.  Just  as  the  clinical  forms 
of  the  usual  epileptic  attacks  in  the  course  of  experience  have  been  enlarged 
by  observation,  so  have  the  psychic  attacks  and  equivalents.  It  may  be  pre- 
sumed with  reason  that  we  are  not  yet  acquainted  with  all  possible  equiva- 
lents, and  that  many  cases  of  extremely  acute  insanity,  especially  transitory 
mania,  raptus  melancholicus,  and  periodic  insanity  in  short  attacks  stand  in 
genetic  relation  to  an  epileptic  neurosis. 

The  clinical  pictures  here  are  extremely  varied.  This  is  espe- 
cially due  to  the  fact,  not  only  that  the  various  equivalents  alternate 
in  the  same  individual,  but  that  they  may  be  combined  in  a  single 
attack.  Just  as  in  the  most  varied  somatic  forms  of  epilepsy,  dis- 
turbance or  loss  of  consciousness  remains  a  constant  distingushing 
feature,  so  in  these  psychic  attacks  this  is  also  a  distinctive  mark. 
They  run  their  course  upon  the  general  basis  of  disturbance  or  loss 
of  consciousness,  which  leaves  but  a  troubled,  summary,  defective,  or 
even  absolute  loss  of,  memory. 


478  SPECIAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

The  forms  of  disturbance  of  consciousness  lying  at  the  basis  of 
these  so  variable  psycho-epileptic  attacks  are:  (a)  stupor;  (b) 
states  of  clouded  consciousness.  Upon  this  foundation,  impulsive 
acts,  delirium,  hallucinations,  states  of  fear,  and  other  elementary 
disturbances  nuiy  arise  as  complications.  The  disturbance  of  con- 
sciousness present  gives  to  these  acts  and  the  delirium  of  the  pa- 
tients an  incoherent,  dreamy,  confused  character — a  feature  that  is 
well-nigh  characteristic. 

The  most  important  transitory  psychic  epileptic  attacks  in  the 
form  of  simple  disturbance  of  consciousness,  or  as  a  coinplieation  with 
other  elementary  psychopathic  symptoms,  are: — 

(aj  Stupor. 

This  occurs  rarely  as  an  independent  manifestation,  usually  as 
a  sequel  of  attacks.  It  may  last  from  half  an  hour  to  several  days. 
It  is  rarely  pure;  for  the  most  part,  it  is  accompanied  by  frightful 
delusions  and  errors  of  the  senses.  Sometimes  instead  of  these  there 
are  religious  delusions  of  an  expansive  content,  characterized  by 
dreamy  incoherence  and  absurdity.  Samt  has  also  observed  ver- 
bigeration, with  profound  dreamy  confusion.  For  the  most  part, 
there  is  mutism.  According  to  this  author,  this  epileptic  stupor  is 
distinguished  from  all  other  kinds  of  stupor  by  difficulty  of  apper- 
ception, profound  disturbance  of  consciousness,  incoherence,  and 
sudden  acts  of  violence. 

Case  44. — Epileptic  stupor. 

G.,  aged  34,  single,  day-laborer,  originally  weak-minded;  epileptic  since 
childhood.  On  August  6,  1873,  he  left  his  home  "because  God  called  him." 
He  was  in  a  state  of  epileptic  delirium,  spoke  confusedly  of  the  devil,  God, 
robbers,  enemies,  with  consciousness  profoundly  disturbed,  apprehensive, 
stuporous  for  hours  at  a  time,  staring  before  him  fixedly.  On  August  12th  he 
came  to  himself  and  remembered  only  that  he  had  been  confused  in  his  head, 
had  seen  flashes  of  fire,  and  had  heard  a  messenger  from  Heaven.  In  the 
asylum  epileptic  attacks  every  tAvo  days,  partly  classic,  partly  consisting  of 
mere  tonic  spasm  with  loss  of  consciousness.  They  occur  without  warning, 
last  several  minutes,  and  leave  behind  a  state  of  cloudy  consciousness  lasting 
several  hours.  "With  the  use  of  potassium  bromide  (G  grams)  they  become  less 
frequent  and  disappear  entirely  in  time.  Since  1874  every  three  or  four 
months  peculiar  states  of  stupor  occur  in  which  the  patient  lies  in  bed  staring 
with  eyes  wide  open,  dilated  and  lazy  pupils,  and  anesthetic  conjunctiva — 
speechless,  without  reaction,  grimacing  play  of  the  facial  muscles.  The  skin 
and  mucou§  membranes  are,  during  an  attack  lasting  eight  days,  remarkably 
pale,  and  the  arteries  greatly  contracted.  The  patient  retains  attitudes  given 
to  him  passively  in  a  cataleptiform  way,  without  presenting  fiexibilitas  cerea. 
He  does  not  sleep  and  he  has  to  be  fed.    He  is  untidy.     Stimulation  of  the 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        479 

skin  and  sensory  organs  produce  no  reaction.  After  eiglit  days  he  comes  to 
himself  and  knows  notliing  of  what  has  liappencd.  In  1877  there  wore  re- 
peated vertiginous  attacks. 

May  1'3,  1877,  during  the  course  of  an  attaciv  of  stupor,  there  was  a  state 
of  psychomotor  excitement  lasting  several  days,  in  which  the  patient,  quite 
unconscious,  danced,  turned  himself  about  in  a  circle,  trembled  throughout  his 
body,  and  verbigerated  constantly  in  a  tone  of  a  preacher  in  a  new,  incompre- 
hensible language  containing  only  broken  German  words.  The  patient  died  of 
phthisis.  May  24,  1877. 

(bj  states  of  Clouded  Consciousness. 

They  appear  as  sequels  of  attacks,  between  attacks,  and  as  inde- 
pendent psychic  disturbance  lasting  from  a  few  hours  to  a  month. 
There  is  variation  of  intensity  during  the  continuity  of  the  phe- 
nomenon. They  rarely  appear  in  a  pure  form,  and  are  usually 
complicated  by  other  elementary  disturbances.  The  following  dis- 
ease-pictures may  be  mentioned  as  especially  important  clinically 
and  f orensically : — 

1.  States  of  clouded  consciousness  with  fear  (petit  mal — Falret) : 
i.e.,  a  state  of  half-conscious,  but  profound,  psychic  depression  which 
is  felt  as  profound  psychic  pain,  attaining  at  times  the  degree  of 
demonomania,  and  associated  with  fear,  confusion  of  thought,  and, 
usually  also,  with  painful  imperative  reproduction  of  a  few  frightful 
ideas.  Under  the  influence  of  this  fearful  cloudiness  and  helpless- 
ness, the  patient  becomes  desperate  and  driven  about  by  fright.  He 
perceives  those  around  him,  for  the  most  part,  as  hostile,  and  assumes 
an  aggressive  attitude  toward  them.  Very  frequentlj^,  under  such 
circumstances,  there  are  destructive  acts — impulsive — toward  his  own 
person,  caused  by  apprehension  and  imperative  ideas;  or  toward 
others  as  the  result  of  a  like  cause  or  of  hostile  apperception.  Brutal 
violence  and  recklessness  characterize  these  destructive  acts.  In 
consonance  with  the  profound  mental  confusion  and  disturbance  of 
consciousness,  for  the  period  of  the  attack,  memory  is  only  summary 
or  cloudy. 

This  disturbance  is  less  frequent  after  epileptic  attacks;  more 
frequent  as  an  independent  manifestation,  and,  according  to  Falret's 
observation,  more  frequent  in  the  vertiginous  than  in  tiie  convulsive 
form  of  epilepsy. 

Case  45.— States  of  epileptic  clouding  of  consciousness  with  ap- 
prehension (petit  mal). 

S.,  salesman,  aged  29.  Mother  neuropathic,  afflicted  with  con^^llsions. 
He  had  convulsions  until  his  fifth  year.  From  that  age  until  his  ninth  year  he 
was  seen  to  walk  in  his  sleep.  Thereafter  the  patient  was  nervous,  irritable, 
and  apprehensive.    From  his  sixteenth  year  he  had  attacks  of  violent  head- 


480  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

ache,  habitual  depression,  morose  character,  great  emotional  irritability.  In 
his  eighteenth  year,  causeless  attempt  at  suicide  by  means  of  matches.  Until 
his  twenty-fifth  year  frequent  attacks  of  causeless  fear  and  oppression,  in 
which  he  wandered  about  with  consciousness  much  disturbed.  These  attacks 
(petit  mal)  lasted  some  hours.  Several  times  a  year  the  patient  sutt'ercd  with 
attacks  of  vertigo,  with  darkness  before  his  eyes  and  disturbance  of  conscious- 
ness (vertigo).  The  patient  became  a  business  man  and  associated  himself  in 
1S75  with  another.  The  business  did  not  prosper.  His  partner  was  not 
strictly  honest.  Since  the  beginning  of  April,  1S7G,  bad  sleep,  headache, 
frightful  dreams,  difficulty  to  distinguish  dreams  from  reality  on  awaking, 
depression  to  the  degree  of  tcvdiiim  utw. 

In  the  night  of  Jlay  5  and  6,  1S76,  he  dreamed  that  his  partner  was  be- 
fore him,  threatening  him.  He  awoke  in  a  confused  state,  sought  a  weapon 
witli  which  to  kill  his  bedfellow,  whom,  in  his  confusion,  he  identified  with  his 
partner.  ^Yhile  seeking  for  a  weapon  he  came  to  himself  and  recognized  the 
danger  he  had  been  in  of  killing  an  innocent  man.  On  the  morning  of  the  6th 
he  was  depressed,  and  in  the  afternoon,  in  order  to  distract  himself,  he  took  a 
Avalk  in  the  park. 

Suddenly  he  became  dizzy,  saw  blackness  before  his  eyes,  and  was  over- 
come with  horrible  fear.  It  seemed  to  him  as  if  the  people  were  rushing  upon 
him  and  pui-suing  him.  Driven  by  unspeakable  fear,  he  ran  away  without 
knowing  where.     In  his  flight  he  still  saw  the  people  indistinctly. 

He  did  not  know  how  long  he  ran  about.  Finally  breathless,  he  asked 
the  police  to  come  to  his  assistance.  Immediately  admitted  into  the  hospital; 
he  seemed  apprehensive.  Consciousness  was  clearly  much  distm'bed.  In  the 
evening  he  became  lucid  and  free  from  fear.  Large  head  (58  centimeters).  A 
scar  on  the  left  side  of  the  tongue.  The  patient  denied  actual  epileptic  at- 
tacks. Since  further  observation  showed  nothing  remarkable,  aside  from  a 
certain  amount  of  depression,  at  his  request  he  was  discharged. 

2.  A  further  stage  of  development  of  the  condition  under  discus- 
sion, due  to  profound  disturbance  of  consciousness  and  complicating 
delusions  and  hallucinations,  is  represented  by  the  so-called  grand 
mal  (Falret) :  i.e.,  a  sudden  outburst  of  violent  hallucinatory,  perse- 
cutory delirium.  The  frightful  content  of  the  delusional  ideas  and 
errors  of  the  senses,  which  consist  principally .  of  horrible  visions, 
ghosts,  and  threats  of  death,  and  the  confusion  and  disturbance  of 
consciousness,  give  to  this  epileptic  delirium  peculiar  features  which 
are  still  more  emphasized  by  the  not  infrequent  episodes  of  stupor, 
as  well  as  occasionally  by  those  of  religious  primordial  delusions.  In 
reaction  to  this  frightful,  apprehensive  content  of  the  profoundly 
disturbed  consciousness,  there  are  violent  psychomotor  acts  in  the 
form  of  blind  violence  toward  the  ghosts  and  toward  others  that  are 
thought  to  be  hostile;  states  of  violent  excitement,  in  which  the 
patient,  whose  rage  does  not  allow  him  to  be  approached,  strikes 
about  him  in  fear  of  death  and  in  despair,  bites  and  spits,  and,  as 
the  records  of  legal  medicine  show,  is  extremely  dangerous  to  others. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        481 

A  rare  variety  of  this  frightful  hallucinatory  delirium  I  have 
called  attention  to  as  hypochondriac  delirium. 

The  subsidence  of  this  state  of  grand  mal  is  sudden,  at  least  as 
far  as  the  delirium  is  concerned,  though  usually  after  its  disappear- 
ance there  is  still  a  condition  of  clouded  consciousness  lasting  hours 
or  days;  or  it  passes  through  a  stuporous  state  to  lucidity. 

The  whole  duration  of  the  attack  may  be  from  a  few  hours  to  a 
few  days.  Memory,  like  that  of  patients  awaking  from  a  dream., 
is  extremely  summary.  As  a  rule,  there  is  defect  of  memory  for  the 
entire  duration  of  the  attack.  These  states  of  delirium  occur  mainly 
in  connection  with  convulsive  epilepsy,  and  usually  as  prodromes  or 
as  sequels  of  classic  attacks,  especially  after  a  series  of  them. 

Case  46. — Delirious  post-epileptic  states  of  clouded  conscious- 
ness (gra.nd  mal). 

M.,  aged  25;,  son  of  an  official,  was  admitted  to  the  clinic  July  9,  1876. 
His  father  was  an  extremely  irritable,  choleric  man.  At  the  age  of  six  weeks 
the  patient  had  a  general  eczema,  which  lasted  until  his  fourteenth  year,  and 
since  then  it  has  recurred  from  time  to  time.  In  his  fourteenth  year  there 
were  at  times  twitehings  in  the  upper  extremities,  with  dizziness  and  clouding 
of  consciousness.  After  a  few  months,  following  cholera,  there  was  a  single 
genuine  epileptic  attack.  Since  then  the  attacks  have  returned  at  intervals  of 
a  few  days  or  a  Aveek.  The  patient  became  irritable,  and  the  mental  develop- 
ment was  retarded. 

Since  the  latter  part  of  1875  there  has  been  post-epileptic  violent  delirium 
about  every  three  months.  After  frequent  attacks,  on  July  9,  1876,  a  state 
of  clouded  consciousness  came  on,  in  which  the  patient  was  sleepless,  and  in 
expression  and  mentally  he  was  profoundly  confused.  On  the  11th,  in  the 
night,  a  violent  frightful  delirium  was  developed.  The  patient  became  very 
much  frightened,  suddenly  got  up,  struck  a  patient,  throttled  him,  cried,  raved, 
and  struck  wildly  about  him.  The  next  morning,  with  astonishment,  he  found 
himself  in  an  isolated  cell.  He  was  still  in  a  state  of  mild  confusion,  and 
could  only  say  that  he  feared  that  he  was  surrounded  with  murderers,  had 
heard  frightful  noises  and  terrible  discharges  of  cannon,  and  had  seen  every- 
thing in  fire  and  blood.  On  the  afternoon  of  the  15th  delirium  again  came  on 
and  lasted  until  the  21st.  The  patient  presented  exactly  the  same  picture  as 
from  the  11th  to  12th.  He  raved  and  cried  for  help.  Head  congested;  pulse, 
120  to  140.  Until  the  23d  the  state  of  clouded  consciousness  continued.  The 
patient  is  treated  with  potassium  bromide  (from  3  to  12  grams  daily).  The 
epileptic  attacks  grow  less  frequent;  still  less  frequent,  hardly  one  a  year, 
are  the  attacks  of  post-epileptic  delirium,  which,  when  they  occur,  conform  to 
the  previous  attacks.  The  epileptic  characte:^  (irritability,  moroseness)  and 
weak-mindedness  do  -not  change.  Now  and  then  the  patient  becomes  suddenly 
aggressive  toAvard  those  around  him  as  a  result  of  illusions  (the  faces  of  those 
around  him  change  into  horrible  masks).  Sometimes  there  are  states  of 
slightly  clouded  consciousness  with  abrupt  hallucinations  (scolding  voices,  and 
communications  that  his  parents  are  dead,  etc.),  which,  perhaps,  may  be  re- 
garded as  abortive  states  of  delirium. 


482  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Case  47. — Post-epileptic  states  of  frightful  delirium  and  frag- 
ments of  religious  expansive  delirium. 

H.,  aged  25,  son  of  a  farmer,  admitted  February  14,  1875.  He  has  an 
epileptic  sister.  During  the  period  of  dentition  he  had  violent  convulsions, 
began  to  speak  only  at  the  age  of  three,  and  was  imboeile. 

In  1S5S,  without  cause,  epilepsy  began.  The  attacks  occurred  at  first 
two  or  three  times  a  day.  Later  only  once  in  two  weeks,  but  they  were  more 
severe  and  lasted  longer.  Great  emotional  irritability;  progressive  mental 
deterioration.  Since  his  twentieth  year,  now  and  then,  after  frequent  attacks, 
states  of  frightful  delirium.  They  are  quite  typic,  occur  a  few  hours  after  the 
epileptic  attacks,  which  leave  behind  a  state  of  profound  mental  confusion, 
and  last  as  long  as  a  week.  Snapping  of  the  fingers,  visions  of  his  father 
threatening  him,  and  hostile  perception  of  those  around  him  always  introduce 
the  delirium.  During  its  continuance  there  is  profound  disturbance  of  con- 
sciousness and  confusion:  "All  will  be  made  clear — the  Almighty  does  not 
abandon  me — you  are  killing  me — \Ve  shall  meet  in  hell."  The  patient  raves, 
fights  witli  the  attendants,  defends  liimself  desperately,  wUl  wear  no  clothiiig, 
tears  up  everything,  and  rolls  in  straw.  Episodically,  usually  toward  the  end 
of  the  paroxysm,  the  patient  sings  and  shouts,  and  makes  out  of  straw, 
clothing,  etc.,  a  kind  of  altar;  dances  around  it,  and  think§  he  is  in  Heaven. 
The  state  of  disturbed  consciousness  outlasts  the  delirium  some  hours  or  days. 
There  is  absolute  amnesia  for  all  the  events  of  the  attack.  The  patient  has 
convergent  strabismus  that  has  existed  from  youth.  The  left  pupil  is  more 
widely  dilated  than  the  right.  The  patient  could  not  be  brought  under  regular 
bromide  medication.  After  a  short  stay  in  the  hospital  there  was  statita  cpl- 
lepticus  and  death. 

3.  States  of  clouded  consciousness  with  religious  expansive  de- 
lirium.^ Clinical  appreciation  of  these  not  infrequent  deliria  in  epi- 
leptics belongs  to  recent  times.  They  may  be  regarded  as  equivalents 
of  the  foregoing;  and  they  likewise  occur  paroxysmally  and  in  dis- 
tinct attacks.  They  are  concerned  Avith  divine  visions  and  divine 
things  ("divine  nomenclature'"^ — Samt).  The  patients  take  them- 
selves to  be  God,  Christ,  prophets,  and  think  they  are  in  Heaven,  to 
Avhich  ideas  muscular  anesthesia  and  the  consequent  delusions  of 
flying  to  Heaven  contribute.  The  patients  during  their  delirium  are 
in  hallucinatory  relation  with  God,  receive  revelations,  commands, 
and  the  like;  for  example,  to  murder  their  relatives  that  they  may 
go  to  Heaven.  Those  around  them  are  frequently  taken  to  be  Jews 
or  wicked  and  threatened.  In  the  midst  of  this  happy  delirium  the 
scene  may  change — the  patient  sees  hell  and  divine  judgment  before 


"•Toselli  ("Ueber  Ptcligiosität  der  Epilepsie,"  Arch.  Italian.,  1S79,  March, 
page  98).  Skae  (Journal  of  Mental  Science,  1874)  calls  attention  to  the  fact 
that  the  epileptic  visions  of  Anna  Lee  gave  rise  to  the  sect  of  Shakers;  that 
Swedenborg's  deliria  created  sects  in  Sweden  and  England;  that  Moliaunncd's 
hallucinations  were  the  origin  of  Islam. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        483 

him,  and  feels  that  he  is  a  repentant  sinner  and  wishes  to  make 
atonement,  but  he  always  comes  out  of  such  episodes  as  a  person  that 
has  received  divine  grace.  These  religious  deliria  are  also  charac- 
terized by  their  impossibility  and  their  fairy-like  character.  The  dis- 
turbance of  consciousness  is,  as  a  rule,  not  very  profound,  and  the 
events  of  the  delirium  are  at  least  remembered  summarily;  but  there 
are  also  cases  with  complete  absence  of  memory. 

Episodically  the  condition  may  be  intensified  to  ecstasy.  Too, 
intercurrent  states  of  stupor  are  observed.  The  delirium  passes 
through  a  state  of  stupor  or  a  state  of  clouded  consciousness  to 
lucidity. 

Case  48. — Epileptic  religio-expansive  delirium. 

T.,  aged  50,  day-laborer.  As  a  small  child  he  had  convulsions,  which  de- 
veloped into  epileps}^  At  first  the  attacks  occurred  only  once  in  two  weeks, 
but  later  presented  the  characteristics  of  classic  epilepsy.  Of  late  years  re- 
ligious delusions  had  been  associated  with  them,  as  a  result  of  which  the 
patient  was  brought  to  the  asylvuu  on  August  4,  1873.  Under  observation  six 
years  in  the  asylum  there  were  genuine  attacks  of  epilepsy  which  occurred  a 
few  days  apart,  preceded  by  increased  emotional  irritability  and  followed  by 
mental  cloudiness  and  confusion  lasting  several  hours.  Potassium  bromide 
had  a  satisfactory  effect.  There  are  no  anomalies  of  the  skull  or  vegetative 
disturbances  of  importance.  There  is  clearly  a  moderate  degree  of  mental 
enfeeblement.  The  patient  is  a  prototype  of  the  epileptic  character:  a 
morose,  irritable,  bigoted,  hypocritical  man,  who  has  always  the  name  of  God 
on  his  lips,  the  prayer-book  in  his  pocket,  bemoans  the  wickedness  of  the 
world,  turns  his  eyes  up  when  there  is  anything  said  of  divinity  or  of  heavenly 
love  and  goodness,  but  when  a  fellow-patient  disturbs  his  devotion  and  Phari- 
saic calm  in  the  slightest  he  acts  in  the  most  brutal  way.  When  he  is  dis- 
turbed in  his  prayer  at  table,  he  immediately  falls  upon  others,  provoking 
quarrels  and  declaring  religion  in  danger. 

He  keeps  apart  from  others,  does  not  work,  lives  in  God  and  the  thought 
of  eternity,  and  regards  his  being  in  the  asylum  as  martyrdom  for  which  God 
will  recompense  him.  Three  or  four  times  a  year,  sometimes  before,  some- 
times after  a  series  of  attacks,  less  frequently  without  attacks,  and  then  usu- 
ally as  a  result  of  anger,  the  patient  becomes  alternately  irritable  and  agi- 
tated. He  scolds  terribly  about  his  wicked  and  sacrilegious  companions.  His 
consciousness  becomes  clouded,  he  looks  upon  others  as  the  devil,  thinks  that 
religion  is  in  danger,  that  he  must  defend  it  and  destroy  the  enemies  of  God. 
He  raves  blindly  around  and  asks  to  be  crucified  for  the  true  faith.  At  the 
height  of  the  paroxysm  he  falls  into  ecstasy,  shouts,  sees  God  face  to  face, 
strikes  his  breast,  and  says  that  he  is  the  true  man  of  God,  Christ,  the  true 
defender  of  God,  prophet  and  martyr.  He  wished  to  let  himself  be  crucified 
for  the  true  faith,  but  when  he  was  about  to  carry  it  out  he  had  noticed  that 
another  was  on  the  cross.  Episodically  he  raves  and  rages  about  his  sacri- 
legious companions  whom  he  takes  for  the  devil,  sinners,  damned,  etc. 

During  this  religious  period  consciousness  is  decidedly  clouded,  but  it  is 
still   possible   for   external  impressions   to   reach   it.     In   harmony   with   this, 


484  SPECIAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

there  is  no  defect  of  memory  left  behind.     The  patient  remembers  his  divine 
visions  and  does  not  correct  them. 

The  attacks  are  typically  congruent,  the  only  difl'erence  being  that  some- 
times they  last  one  day,  and  sometimos  five  or  six  days.  A  state  of  clouded 
consciousness  and  grea,t  irritability  funns  the  tran.silion  to  the  condition 
dm-ing  the  intervals. 

4.  Peculiar  states  of  clouded  consciousness  with  dreamy  romantic 
ideas,  usually  of  expansive  content,  which,  with  the  varying  condi- 
tion of  consciousness,  appear  now  as  mere  imperative  ideas,  now  as 
delirium.  The  patient,  apparently  himself  and  acting  and  speaking 
consciously,  is  nevertheless  in  a  dreamy  state  of  clouded  conscious- 
ness comparable  to  that  of  the  somnambulist.  He  acts  in  accordance 
with  his  dreamy  romantic  ideas,  carries  out  his  delusional  role  or 
mission,  and  as  a  result  comes  into  dangerous  conflict  with  actuality 
and  his  real  interests.  Thus  there  may  be  wandering,  vagabondage, 
desertion,  cheating,  theft,  and  the  like,  for  which  the  patient  has 
merely  a  summary  or  no  memory  at  all.  The  duration  of  these  states 
is  from  hours  to  months.  It  seems  that  they  occur  only  in  individ- 
uals not  subject  to  classic  attacks  of  epilepsy,  or  who  have  them  in- 
frequently, or,  in  their  place,  vertigo  or  attacks  of  fear. 

Case  49. — Epileptic  dream-states. 

Iglow,  aged  25,  a  baker,  father  a  drunkard,  showed  from  childhood  a 
persistent  angry  temperament,  suffered,  with  nystagmus  and  in  his  fourteenth 
year  began  using  alcohol  to  excess,  since  which  time  he  has  occasionally  done 
peculiar  acts  while  in  a  dazed  condition  and  without  definite  subsequent 
knowledge  of  them:  e.g.,  swimming  a  river.  In  his  sixteenth  year  he  was 
suddenly  seized  with  the  impulsive  idea  that  he  was  the  Prince  of  Servia,  and 
it  was  with  dilBculty  that  he  restrained  himself  from  believing  it.  In  1866  he 
was  in  an  asylum  three  months  on  account  of  confusional  insanity.  During 
this  time  he  imagined  he  was  the  Prince  of  Servia,  and  the  idea  often  came  to 
him  after  he  was  discharged  from  the  asylum. 

In  1867,  without  any  reason,  he  ran  away  from  his  work,  threw  away  his 
possessions,  squandered  his  money  in  drink,  wandered  about  in  a  dazed  condi- 
tion for  three  days,  then  became  conscious,  realized  what  a  foolish  thing  he 
had  done.,  and  was  ashamed  of  his  conduct. 

In  18Ü8  he  was  a  second  time  placed  in  an  asylum,  suffering  in  the  same 
way  as  when  confined  before. 

In  1869,  after  his  second  discharge,  he  suffered  at  times  with  great 
anxiety,  would  awake  from  terrorizing  dreams  with  fear,  and  at  such  times 
noticed  a  cramp  in  the  toes  of  left  foot.  The  dazed  mental  condition  and 
purposeless  acts  were  noticed  especially  after  alcoholic  excesses. 

In  1871  he  had  his  first  typic  epileptic  attack,  which  was  preceded  by  fear 
and  accompanied  by  spasmodic  contraction  of  hands.  He  was  before  a  bake- 
oven,  called  for  help,  and  became  unconscious.  After  this  attack  he  abstained 
from  drinking  and  remained  well  until  November  24,  1874,  when  he  had  re- 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        435 

peated  epileptic  attacks  which  caused  him  to  discontinue  his  work.  Without 
means  he  went  to  live  with  his  brother,  drank  excessively,  and  passed  into  a 
dazed  condition.  One  day,  to  his  great  surprise,  he  was  arrested,  and  was  in- 
formed that  he  was  guilty  of  "Idse  majefiU."  He  was  in  prison  two  months; 
there  he  became  delirious,  and  one  day  declared  himself  the  Prince  of  Servia 
and  wished  to  return  to  his  army  in  Belgrade,  etc.  When  he  arrived  in  the 
asylum  where  he  was  sent,  his  mind  was  clear  and  he  corrected  and  laughed 
at  his  foolish  ideas,  with  only  a  sort  of  vague  recollection  of  what  had  occurred 
while  he  was  delirious.  Observations  made  at  this  time  showed  mental  in- 
tegrity, nystagmus,  paresis  of  left  angle  of  mouth.  Once  he  awoke  with  fear 
and  cramp  of  toes  of  left  foot.  After  this  time  no  further  epileptic  manifesta- 
tions were  observed. 

5.  Confused  states  with  excitement  in  the  form  of  moria  lasting 
hours  or  days.  This  very  infrequent  form  of  epileptic  transitory 
disturbance,  in  which  the  patients  present  the  picture  of  apparent 
moria  (silly  activity,  laughing,  silly  jokes,  making  faces,  tricks,  etc.), 
but  which,  owing  to  profound  disturbance  of  consciousness  and  defect 
of  memory  are  clearly  separated  from  similar  conditions  in  simple 
maniacal  insanity,  has  been  repeatedly  observed  by  Samt,  with  con- 
secutive or  episodic  stupor. 

Case  50. — Epileptic  states  of  confusion  with  excitement  in  the 
form  of  moria. 

B.,  aged  25,  daughter  of  a  day-laborer.  From  childhood  epileptic  and 
imbecile.  She  was  found  in  a  field  some  miles  from  her  home  in  a  state  of 
profound  confusion,  singing  and  dancing,  and  brought  to  the  asylum.  There 
she  had  frequent  and  usually  grouped  attacks  of  classic  epilepsy,  which  re- 
curred at  intervals  of  a  few  days.  Thereafter,  and  sometimes  also  as  an  inde- 
pendent phenomenon,  there  were  typic  congruent  paroxysms  of  moria-like 
excitement  lasting  as  long  as  three  days,  which  differed  from  analogous  condi- 
tions that  occur  in  mania  only  in  the  profound  mental  confusion  and  disturb- 
ance of  consciousness. 

The  patient  began  suddenly  to  sing,  to  make  pleasant  faces,  and  to  talk 
incessantly  and  incoherently.  She  shook  with  laughter,  danced  around,  took 
grotesque  attitudes,  rolled  on  the  floor,  flirted  with  the  doctors  and  the 
patients,  whom  she  absolutely  mistook,  undressed,  arranged  her  hair,  and  ran 
around  the  ward.  Pulse  small,  artery  contracted,  extremities  cool,  sleepless- 
ness during  the  continuance  of  the  state  of  excitement.  The  profound  state 
of  clouded  consciousness  outlasted  the  excitement  from  a  few  hours  to  a  day. 
Absolute  amnesia  for  the  paroxysms,  which  occurred  two  or  three  times  a 
month.     Potassium  bromide  was  without  effect. 

It  is  of  the  greatest  importance  to  recognize  the  neurosis  which 
lies  at  the  bottom  of  these  protean  clinical  pictures.  Important 
points  in  this  sense  are :  the  etiology  of  the  case,  the  history,  the  ap- 
preciation of  the  symptoms  during  the  intervals,  the  symptoms  of  the 
attack,  and  the  comparison  of  one  attack  with  another. 


486  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

1.  With  respect  to  cause,  the  important  points  arc:  hereditary 
predisposition,  trauma  capitis,  and  rickets. 

2.  In  the  history,  the  object  is  to  search  for  the  presence  of  any 
suspicious  attacks  which  miglit  be  epileptic.  In  this  direction  ini- 
[)ortant  points  are  convulsions  in  childhood,  attacks  of  nocturnal  fear, 
sleep-walking,  along  with  other  attacks  which  are  recognized  by 
science  as  epileptic  or  opileptoid.  Special  attention  must  be  directed 
to  indicatious  of  nocturnal  attacks  occurring  in  sleep  {vide  page  4TT). 

3.  The  S3'mptoms  during  the  intervals  are  of  the  greatest  sig- 
nificance (epileptic  character) :  elementary  psycho-cerebral  disturb- 
ances, signs  of  epileptic  degeneration. 

•i.  The  following  speak  for  the  epileptic  nature  of  a  psychic 
attack : — 

(a)  Its  occurrence  with  aura-like  symptoms  like  those  that  occur 
before  the  ordinary  epileptic  attacks. 

(h)  Suddenness,  short  duration,  and  sudden  disappearance  of 
the  symptoms,  like  those  that  occur  after  vertiginous  and  classic 
epileptic  attacks,  especially  stupor. 

(c)  In  the  attack  itself:  the  exquisite  frightful  character  of 
the  delirium  and  hallucinations,  and  also  the  divine  nomenclature, 
especially  when  it  occurs  with  the  former;  and  further  the  profound 
disturbance  of  consciousness,  the  dream-like  incoherence,  and  the 
episodic  occurrence  of  stupor. 

(d)  Imperfect  memory  or  absolute  amnesia  for  the  events  of 
the  attack.  As  Samt  showed,  memory  may  be  present  immediately 
after  the  attack,  but  then  is  lost. 

(e)  The  comparison  of  attacks,  in  so  far  as  they  are  typically 
congruent,  or  at  least  (there  are  often  equivalents)  when  it  is  pos- 
sible to  discover  the  recurrence  of  certain  attacks  which  resemble  one 
another. 

(f)  The  acts  of  the  patients  in  such  attacks,  owing  to  the  pro- 
foundly dream-like  or  clouded  state  of  consciousness,  with  the  inco- 
herence of  ideas,  the  frightful  character  of  the  dreamy  consciousness 
filled  with  delusions  and  errors  of  the  senses — at  least  in  the  forms 
of  petit  and  grand  mal — are  without  motive,  aimless,  reckless,  sudden, 
noisy,  without  consideration  of  means,  and  often  absolutely  impulsive 
outbreaks  of  blind  rage  and  violence. 

3.  Protracted  Equivalents. 

In  epileptics  there  are  attacks  of  delirious  insanity  that  last 
several  weeks  or  months,  and  which,  owing  to  certain  clearly  defined 
features,  point  directly  to  the  epileptic  basis  and  are  specific.    We 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        4^7 

owe  tliis  knowledge  to  Samt,  who  even  regards  it  as  proved  t?iat  \>y  the 
specific  characters  of  epileptic  insanity  it  can  be  identified  when  there 
are  no  other  epileptic  antecedents. 

As  the  specific  signs  of  epileptic  insanity  Samt  recognizes :  acute 
outbreak;  predominating  states  of  fear  with  mixture  of  frightful  de- 
lusions and  corresponding  hallucinations,  for  the  most  part,  about 
danger  of  death;  especially  the  crowding  of  masses  of  forms  around, 
so  frequent  in  epileptics,  interrupted,  however,  by  delusions  of  gran- 
deur, especially  of  a  religious  character;  divine  nomenclature,  great 
irritability,  and  relative  lucidity  with  actual  state  of  clouded  con- 
sciousness; gradual  subsidence  of  the  attack  and  various  forms  of 
defect  of  memory  for  the  events  of  the  attack;  further,  reckless 
acts  of  extreme  violence;  stupor  with  characteristic  reaction  in 
speech  of  various  degrees  of  intensity;  finally,  various  degrees  of 
incoherence,  of  partial  lucidity,  on  the  one  hand  going  to  the  extent 
of  dream-like  absurdity  and  incoherence,  and,  on  the  other,  to  illu- 
sional  and  hallucinatory  incoherence,  like  that  of  delirium  tremens. 

The  forms  under  consideration  here  in  large  part  are  protracted 
psychic  equivalents,  or  perhaps,  more  correctly,  repeated  relapses  that 
are  at  the  same  time  protracted.  These  conditions  might  quite  as 
correctly  be  called  epileptic  hallucinatory  insanity.  After  leaving 
aside  such  cases  as  have  no  certain  epileptic  antecedents  (as  should 
be  done  in  a  text-book)  there  have  come  under  my  observation  cases 
of  petit  and  grand  mal,  of  religious  delirium,  and  of  stupor,  in  har- 
mony with  the  description  set  forth  above. 

These  states  have  in  common:  the  prolonged  profound  disturb- 
ance of  consciousness  (especially  of  apperception),  more  marked  than 
in  the  ordinary  psychosis;  the  great  confusion  of  thought;  the  pro- 
found remissions  which  may  become  intermissions  of  the  delirium, 
with  which,  however,  there  are  then  usually  states  of  clouded  con- 
sciousness and  stupor;  the  very  siraimary  memory  or  amnesia  for  the 
events  of  the  attacks;  finally,  the  sudden  outbreak  and  subsidence 
through  a  stage  of  clouded  consciousness  and  stupor. 

Case  51. — Protracted  post-epileptic  delirium. 

C,  aged  25,  student,  admitted  to  the  psychiatric  clinic  December  7,  1881. 
His  mother  was  insane.  He  developed  slowly  and  was  of  weak  mental  power. 
In  his  fifteenth  year  he  became  insane  and  passed  two  years  in  an  asylum. 
According  to  the  description  given  he  had  monthly  attacks  lasting  fourteen 
days,  exactly  like  those  to  be  described.  Thereafter  he  was  well,  sober,  in- 
dustrious. In  the  last  half  of  November,  1881,  he  had  facial  erysipelas  with 
moderate  fever.  December  4,  1881,  he  was  peculiarly  oppressed.  He  went  to 
church  and  referred  some  of  the  passages  in  the  sermon  concerning  sin  and 


488  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

death  to  hiuiself.  He  went  home,  wept,  was  depressed,  disturbed,  pale,  looked 
cast  do^^•I^,  and  complained  of  violent  headache.  In  bed  he  noticed  that  the 
whole  room  was  raised  up  in  the  air  with  himself.  It  seemed  to  him  as  if  God 
was  pulling  him  up  by  the  hair.  He  felt  the  loAver  part  of  his  body  ice-cold, 
and  looking  dovm  he  saw  a  dark  chasm.  He  prayed  from  fear,  felt  animals 
biting  his  body,  asked  God  not  to  lot  him  sufl'er  too  much.  Then  he  felt  him- 
self sink  back  to  the  earth,  and  the  animals  retire  to  an  abyss. 

On  the  morning  of  the  5th  he  went  to  his  classes.  There  he  heard  a 
voice:  "What  would  you  do,  you  who  have  suffered  for  so  many  souls  (of  the 
damned)?"  Since  he  was  crying  and  disturbe<l,  he  was  sent  home.  There  he 
was  taken  with  anguish.  He  took  a  prayer-book  and  read  something  about 
the  grave,  and  became  ice-cold. 

On  the  6th  and  7th,  with  disturbed  expression  and  violent  headache,  he 
lay  sleepless  in  bed.  On  admission  his  expression  was  profoundly  disturbed, 
apprehensive,  incoherent,  and  he  rolled  on  the  floor  from  headache.  No  pain- 
ful points,  sj-mmetric  head,  no  fever,  no  vegetative  findings.  Until  December 
ISth  the  patient  is  sleepless,  with  the  exception  of  some  sleep  obtained  by 
chloral;  profoundly  confused;  depressed,  with  the  exception  of  short  episodes 
of  relative  clearness  of  consciousness.  He  frequently  sings  hymns,  praj's  much 
in  order  to  get  relief  and  because  the  day  of  judgment  is  at  hand.  He  tells  of 
voices,  says  he  is  a  great  sinner,  and  talks  of  music  that  he  hears.  He  sees 
the  devil,  ghosts,  nude  women,  Christ  saying  mass,  Deatli.  Death  has  struck 
him  dead.     Often  odors  of  blood;    also  of  roses  and  violets. 

December  ISth  the  patient  becomes  free  and  no  longer  hallucinated,  but 
remains  slightly  clouded  in  consciousness.  He  has  summary  remembrance  for 
the  delirious  events.  He  relates  that  he  saw  hell,  a  ghost  without  a  head. 
Heaven  open  in  three  sections,  heard  angels'  voices;  had  sometimes  pleasant, 
sometimes  unpleasant  odors;  thought  himself  at  the  day  of  judgment,  and 
had  a  feeling  of  happiness  at  being  among  the  chosen.  He  denies  epileptic 
antecedents.  No  history  of  the  patient  was  obtainable  from  other  sources. 
After  January  4,  1882,  he  is  less  lucid,  but  depressed,  taciturn,  and  thinks  that 
if  he  had  not  prayed  so  much  he  would  have  been  lost. 

January  8th  he  has  a  genuine  epileptic  attack.  Thereafter  the  patient  is 
much  disturbed  in  consciousness  and  clouded.  He  himself  complains  of  being 
sick  and  confused  in  his  head,  says  he  had  not  slept  in  the  night,  that"  when 
he  got  up  in  the  night  he  was  dizzy  and  had  once  fallen.  He  had  heard  con- 
stant grinding  of  the  teeth;  had  an  oppressed  feeling  as  if  he  were  at  the  day 
of  judgment.  In  the  early  morning  he  saw  a  dark-yellow  curtain  before  the 
window  torn  in  the  middle  just  like  the  rent  curtain  of  the  temple  at  the  death 
of  Christ. 

In  the  course  of  the  day  the  patient  was  more  and  more  confused  and 
depressed  (6  grams  of  potassium  bromide  daily).  In  the  evening  has  incom- 
])lete  delirium,  sees  Heaven,  hell,  purgatory,  the  yellow  curtain  covered  with 
the  tears  of  the  dead.  He  is  sleepless,  anxious,  depressed,  sings  hymns,  and 
on  the  morning  of  the  9th  tells  of  his  visionjS,  of  trumpets,  and  other  noises;  of 
the  perfume  of  violets,  of  the  presentiments  of  his  deliverance,  and  of  his 
celestial  beatitude.  During  the  night  of  the  9th  to  the  10th  he  sees  Abraham, 
Isaac,  Moses,  Christ,  and  God  the  Father.  It  was  a  terrible  night.  He  ap- 
peared before  the  celestial  tribunal.  It  was  the  last  day  of  judgment,  but  he 
was  counted  among  the  just.    In  spite  of  that  he  is  anxious,  oppressed,  de- 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        489 

pressed,  and  in  a  weeping  voice  says  that  he  is  Christ,  and  in  irritation  that  the 
cursed  H.  had  already  tortured  him  in  hell.  He  begins  suddenly  to  talk  with 
Death,  whom  he  sees  in  a  corner.  Irrita,ted,  delirious,  confused  in  the  after- 
noon, he  thinks  he  is  in  the  Holy  Tomb  and  he  will  arise  to  Heaven  when  the 
last  judgment  is  finished. 

The  night  of  the  11th  he  is  sleepless,  prays,  sings  "alleluia,"  proclaims 
himself  Christ,  reads  the  mass,  lies  at  times  in  the  position  of  one  crucified, 
communicates  with  angels,  kisses  them,  and  fights  with  devils. 

In  the  course  of  the  day,  with  a  pathetic  manner,  he  declares  that  he  is 
Christ,  the  master  of  emperors  and  popes,  the  emperor  of  the  world,  proclaims 
decrees,  prays,  recites  the  ten  commandments,  sings  psalms,  and  says  he  sees 
the  Red  and  the  Blue  Seas.  On  the  12th  he  is  himself  for  a  moment,  recog- 
nizes those  around  him,  and  then  he  bends  his  head  back  in  cramp,  opens  his 
mouth  wide,  and  says:  "Now  I  am  dead."  The  remainder  of  the  day  he  is 
dreamily  delirious,  absorbed  in  inner  events,  often  falls  on  the  floor  and  lies 
there  iu  the  position  of  the  crucifixion.  At  times  he  preaches,  acts  the  part 
of  Christ,  talks  of  heathen,  Christians,  Turks,  and  blood-money  that  has  been 
paid  for  him.  His  grandfather  is  the  Old  Testament,  he  is  the  New  Testament. 
Christianity  falls  into  the  hands  of  the  heathen.  There  is  only  one  God  and 
Mohammed  is  his  prophet.  The  patient's  consciousness  is  profoundly  dis- 
turbed. There  is  great  irritability.  He  strikes  the  floor  with  his  fists  and 
takes  those  around  him  to  be  the  devil.  The  night  of  the  13th  he  is  sleepless, 
sings,  prays,  and  cries  out  in  rage. 

On  the  13th  for  a  moment  he  thinks  he  is  in  the  asylum,  then  in  the 
Holy  Tomb.  He  is  the  Crown  Prince  Rudolph,  and  he  takes  those  around  him 
for  the  emperor  and  apostles.  In  the  afternoon  he  is  seen  in  the  position  of 
one  taking  an  oath.  Then,  profoundly  contrite,  he  throws  himself  down  on  his 
abdomen  and  strikes  his  face  and  breast  crying,  "I  have  never  killed  anyone; 
I  was  foolish;  asylum.  I  was  never  a  God,  never  an  emperor,  never  Satan. 
I  said  I  was  Christ;  I  am  Christ  with  the  crown  of  thorns,  because  I  was 
never  a  forger  of  banknotes  and  never  stole  thirty  kreutzers."  The  patient  is 
constantly  sleepless,  contrite,  profoundly  confused.  Has  repeatedly  all  the 
pain  of  the  last  judgment  day.  Conceals  himself  in  his  straw,  which  he  takes 
to  be  the  Holy  Sepulcher.  Cries  desperately,  and.  occasionally  has  attacks  of 
clonic  spasms. 

After  a  good  night  on  the  20th  the  patient  is  temporarily  in  a  remission, 
but  much  exhausted. 

On  the  22d  apprehensive  delirium  begins  again:  he  is  again  before  a 
court.  Soldiers  shoot  at  him.  He  sees  a  crowd  of  devils,  of  corpses  with  red 
flags;  God  the  Father;  angels  bring  wine  to  comfort  him,  but  he  dare  not  par- 
take of  it. 

On  the  26th  the  delirium  subsides.  Consciousness  becomes  somewhat 
clearer,  but  the  patient  remains  in  a  dreamy  state,  contrite  and  oppressed,  still 
sees  now  and  then  the  judgment  and  spirits.  Again  on  the  28th  the  patient  is 
in  an  exacerbation.  The  delirium  presents  a  coarse  mixture  of  frightful  and 
pleasant  situations,  the  former  predominating.  They  are  about  judgment, 
martyrs,  crucifixion,  blood,  and  war;  blood  which  the  patient  sheds  fighting 
by  the  side  of  Radetzky  against  the  Italians ;  then  for  a  time  he  is  Satan,  and 
cries  about  the  horrors  of  hell — how  he  bled  and  burned  there.  Episodically 
again  he  is  the  emperor,  Christ,  and  in  the  Holy  Sepulcher  (straw).     He  takes 


490  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tlie  physician  to  be  the  crown  pi-ince,  and  asks  him  whether  he  wishes  to  cut 
otl"  his  head.  Tliis  had  happened  seven  times.  At  night  he  sees  war  and  blood, 
and  speaks  of  cotfins.  As  a  reaction  to  the  numerous  changing  delusions,  he 
is  at  times  contrite,  anxious,  despairing,  trembling  with  fear  of  death;  at 
times,  angry  to  aggressiveness.  At  other  times  he  is  happy,  reading  the  mass 
and  singing  hymns.  He  is,  however,  continually  irritable,  changed  in  expres- 
sion, sinister,  and  confused. 

On  February  18th  the  patient  falls  sick  with  a  fever  (-10.2°  C;.)  and  vio- 
lent headache.  Tlie  dcliriiun  ceases  at  once.  The  patient  seems  quite  lucid, 
but  peculiarl}-  afleeted  in  the  sensoriiun.  On  the  19th  an  epileptic  attack. 
The  following  days  the  temperature  varies  between  38.4°  and  39.8°  C.  Violent 
headache,  vomiting,  stiffness  of  the  neck,  and  i>hotophobia  make  a  diagnosis  of 
meningitis  of  the  convexity  more  and  more  certain.  On  the  22d,  at  4  o'clock 
in  the  morning,  a  series  of  epileptic  attacks  in  which  tlie  patient  died  at  5 
o'clock  with  symptoms  of  pulmonary  edema.  Autopsy:  Diffuse  purulent 
leptomeningitis,  cerebral  liypiMeniia,  loft  liypostatic  pneumonia  witli  com- 
mencing pleurisy. 

If.  Chronic  Epih'iitic  Psyclioscs. 

Though  relatively  infrequent,  chronic  psychoses  are  observed 
(Esquirol,  Morel,  Griesinger,  A^^estphal,  Gnanck)  that  differ  in  no  way 
from  those  that  arise  npon  a  non-epileptic  foundation,  and  therefore 
cannot  be  regarded  as  specifically  epileptic.  Experience  also  goes  to 
show  that  upon  the  basis  of  epilepsy  disease-pictures  of  the  ordinary 
psychoses  occur  which  are  modified  in  course  and  symptoms  by  the 
special  neurotic  foundation. 

Aside  from  dementia,  which  occurs  so  frequently  as  a  result  of 
epilepsy,  and  to  which  Sommer,  Bourneville,  and  d'Ollier  ascribe 
peculiar  features,  this  is  also  probably  true  of  certain  cases  of  periodic 
insanity  in  the  form  of  delirium. 

The  cases  of  epileptic  psychoses  thus  far  observed  seem  to  belong 
exclusively  to  the  psychic  degenerations. 

The  prognosis  of  the  single  attack  of  insanity  is  favorable.  The 
general  prognosis  of  epilepsy  with  mental  disturbance  is  bad ;  and  in 
cases  where  epileptic  degeneration  has  once  begun  it  is  quite  hopeless. 

Concerning  the  anatomic  foundation  of  epilepsy  there  is  still  great  un- 
certainty. The  most  various  conditions  are  found.  It  is  probable  that  often 
there  are  congenital  developmental  disturbances  of  the  brain,  glioma  of  the 
cortex,  but  especially  partial  encephalitis,  as  the  foimdation  of  the  trouble. 
To  the  latter  the  sclerosis  of  Amnion's  horn  emphasized  by  Meynert  must  be 
attributed  (Henkes,  Allgemeine  Zeitschrift  für  Psijcliiatrie,  34,  page  38).  Too, 
concerning  the  anatomic  basis  of  the  psychic  disturbances  of  epilepsy,  we  can 
only  advance  assumptions  amounting  to  the  theory  that  they  depend  upon 
vasomotor  disturbances,  just  as  epilepsy  in  general  seems  to  be  a  vasomotor 
neurosis  of  the  central  organ. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        49 1 

Atrophy  of  the  brain,  cloudiness  of  the  membranes,  have  been  found  now 
and  then  in  individuals  who  have  died  in  the  last  stages  of  epileptic  degenera- 
tion, and  these,  in  a  measure,  explain  tlie  mental  deterioration  of  such  un- 
fortunates. 

The  modern  treatment  of  epilepsy,  and  thus  of  epileptic  in- 
sanity, seeks  to  diminish  the  abnormal  excitability  of  the  brain  and 
render  tlie  affected  centers  inexcitable  to  stimuli  which  might  pro- 
voke attacks. 

The  best  of  all  remedies  now  at  our  command  are  the  bromine 
salts. 

Hughes  Bennett  found  that  under  treatment  with  bromides  in  12.1  per 
cent,  of  his  cases  the  attacks  disappeared  entirely;  in  83.3  per  cent,  there  was 
decided  improvement;  in  2.3  per  cent,  no  result;  and  in  2.3  per  cent,  increase 
in  the  number  of  attacks.  There  is  no  doubt  that  in  a  few  cases  by  persistent 
treatment  with  bromides  during  several  years  cures  can  be  effected.  All  the 
bromine  salts  can  be  used,  but  their  combination  and  administration  in  car- 
bonic acid  water  is  especially  to  be  recommended  ("Erlenmeyer's  bromide 
Avater").  The  combination  of  the  bromides  with  aqueous  extract  of  bella- 
donna is  commended  by  Ball  and  others. 

The  lowest  daily  dose  with  which  we  can  hope  to  produce  an  effect  is  6 
grams  (males)  or  4  grams  (females)  for  adults.  Watery  solution  is  the  best. 
Repeated  daily  doses  of  from  2  to  3  grams  diluted  as  much  as  possible  are 
more  advantageous  than  less  frequent  larger  doses  in  concentrated  form. 
The  initial  dose  should  be  increased  slowly  under  observation  of  its  effect  upon 
the  attacks  and  the  organism.  Usually  under  10  grams  the  effect  will  have 
been  obtained.  If  for  any  reason  it  becomes  necessary  to  discontinue  the  use 
of  bromides,  it  should  never  be  broken  off  suddenly,  for  abrupt  suspension  may 
cause  frequent  intense  attacks,  and  even  the  occurrence  of  a  dangerous  status 
epilepticus  is  to  be  feared.  Bromides  may  be  given  for  years  at  a  time  in 
moderate  doses  without  injury  to  the  organism. 

As  an  aid  in  the  treatment  with  bromides  antipyrin  deserves  mention,  in 
about  1-gram  doses  a  day  in  addition  to  the  bromine  salts.  In  cases  that  are 
retractory  to  such  treatment,  I  have  often  had  temporary  success  Avith  amyl 
hydrate  in  doses  of  from  4  to  5- grams  per  day.  This  can  be  administered  for 
months  without  injury  to  the  patient;  also  trional  in  broken  doses, — 0.5  gram 
two  or  three  times  daily, — has  some  effect,  but  I  haA^e  not  yet  had  enough  ex- 
perience with  it.  The  opium-bromide  treatment  of  Flechsig  (six  Aveeks  with 
the  administration  of  opium  gradually  increased  to  1.2  grams  a  day  With  sud- 
den suspension  of  the  opium  and  substitution  of  bromides  to  the  amoimt  of 
7.5  grams  a  day,  and  finally  reduction  of  the  dose  of  the  bromides  after  tA\'o 
months  to  2  grams  a  day)  is  too  little  tested  to  be  decisively  judged.  It  is 
not  Avithout  danger  (scA^eral  fatal  cases,  principally  in  status  epilepticus), 
and  can  only  be  carried  out  in  hospitals.  In  transitory  insanity  and  in  the 
protracted  equivalents  and  chronic  psychoses  of  epileptics,  the  bromides,  the 
best  anti-epileptic  remedy,  have  proved  to  be  Avithout  effect  on  the  attack. 

Inferior  to  the  bromides  are  the  other  anti-epileptic  remedies  (valerian, 
oxide  of  zinc,  silver  nitrate). 


493  SPECIAL  PATHOLOGY  AND  THERAPY  OF  LN^SANITY. 

Tlie  epileptic  should  avoid  coffee,  tea,  alcohol,  and  tobacco.  Vegetable 
diet  is  often  very  useful.  Where  the  epileptic  attacks  occur  frequently,  with 
coma,  hyperpyrexia,  and  danger  of  life,  Krueg,  in  harmonj'  with  Wallis,  has 
demonstrated  the  favorable  ellect  of  chloral  hydrate  by  enema,  or  subcu- 
tiineously  much  diluted,  experimentally  in  epileptic  guinea-pigs  and  in 
epileptics.  [Absolute  restriction  of  the  consumption  of  salt  enhances  the 
eflFect  of  bromides.] 

CHAPTER  in. 
Hysteric  Insanity. 

PsTcnic  anomalies  are  a  constant  occurrence  in  the  rich  and 
varied  symptom-complex  of  hysteria,  though  in  the  majority  of  hys- 
teric patients  these  disturbances  are  only  elementary  (hysteric  char- 
acter). 

Fundamental  manifestations  are  the  unstable  equilibrium  of  the  psychic 
functions,  the  extreme  impressionability,  the  extraordinarily  intense  reaction 
of  the  mind,  and  the  rapid  alternation  of  forms  of  excitement  (irritable  weak- 
ness). The  emotional  anomalies  stand  in  the  foreground.  The  patients  are 
extremely  sensitive  to  internal  and  external  psychic  stimuli.  At  the  height  of 
the  disease  the  feelings  are  no  longer  states  of  humor,  but  affects  (psychic 
hyperesthesia).  Since  the  psychic  processes  are  usually  colored  with  un- 
pleasant feelings,  the  humor  and  affects  are  generally  depressive;  but,  with 
the  rapid  change  of  ideas  and  the  extreme  emotional  excitability,  the  state  of 
feeling  is  not  fixed.  As  a  rule,  there  is  an  alternation  of  feelings  and  affects, 
and  often  a  sudden  change  from  crying  to  laughing.  Since  tue  lively  colored 
ideas  develop  desires,  and  these  are  constantly  changing,  the  patients  seem 
moody  and  inconstant  in  their  feelings  for  persons  and  things.  The  desires 
may  be  very  violent,  and  likewise  the  aversions.  Since  perverse  coloring  of 
feeling  is  possible,  there  are  idiosyncrasies.  Owing  to  the  predominating 
painful  psychic  state  and  the  great  number  of  painful  sensations,  such  patients 
feel  themselves  to  be  very  sick.  Thus  they  become  selfish  and  insensitive  to 
the  suffering  of  others.  Occupied  with  their  own  troubles,  they  are  dull  in 
their  social  and  ethic  feelings,  indifferent  to'sVard  their  duties  and  the  well- 
being  of  their  relatives.  Owing  to  the  lack  of  interest  taken  by  others  in  their 
continual  complaints,  these  patients  finally  come  to  exaggerate  their  sufferings 
and  to  simulate,  in  order  to  excite  interest  at  any  cost  (swallowing  of  needles, 
self-infliction  of  stigmata,  self-injury,  simulation  of  having  been  the  object  of 
violation,  etc.).  In  this  their  abnormally  intensified  imagination  aids  materi- 
ally, and  their  w-eakened  moral  sense  offers  no  obstacle  to  deception  and  lying. 
The  affects  of  such  patients  are  the  most  violent  w^hen  they  do  not  succeed, 
and  they  think  they  are  abandoned  and  not  considered.  Then  their  ugliness 
and  desire  for  revenge  know  no  limits?,  As  an  elementarv  disturbance  of 
thought  there  is  now  increased,  now  slowed  ideation,  with  occasionally  discon- 
nected thought.  The  emotional  and  intellectual  impressionability  of  the 
patients  leads  easily  to  imperative  ideas.  Weakened  power  of  exact  reproduc- 
tion, associated  with  intensified  imagination,  distorts  the  memory  and  causes 
the  patients  to  seem  to  be  liars.  Occasionally,  at  the  time  of  the  menses  and 
at  the  height  of  affects,  there  may  be  primordial  delusions  of  persecution. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        493 

Frequently  the  sexual  sphere  is  also  abnormally  affected.  Sexual  feeling 
may  be  intensified  to  lust  (incubus,  succubus  of  the  Middle  Ages),  and  ex- 
presses itself  in  the  most  remarkable  acts  (going  about  naked,  nymphomania, 
smearing  with  doubtful  cosmetics,  even  urine,  etc.).  At  times  there  may  be 
again  frigidity  in  general,  or  only  as  an  idiosyncrasy  toward  the  husband  or 
lover.  Not  infrequently  there  are  also  temporary  perverse  sexual  feelings 
with  corresponding  impulses,  or  equivalent  manifestations  of  religious  exalta- 
tion. The  vasomotor  sphere,  which  is  always  implicated,  gives  rise  to  pre- 
cordial distress  and  attacks  of  fear. 

The  imagination  of  these  patients  is  usually  abnormally  intensified,  so 
that  lively  thought  easily  leads  to  hallucinations;  or^the  patients  are  unable 
at  least  W:o  distinguish  between  imagination  and  reality^  Frequently  there  are 
also  spontaneous  hallucinations,  and  almost  exclusively  in  the  domain  of 
sight.  Their  content  is,  for  the  most  part,  unpleasant  (death  heads,  ghosts, 
fantastic  animals,  dead  relatives,  etc.).  'Elusions  of  sight  are  not  less  fre- 
quent (distorted  features  of  persons;;  people  seem  shorter,  taller,  etc.);  and 
there  are  also  illusions  of  cutaneous"  sensibility  due  to  false  interpretations  of 
actual  sensations  (snakes,  toads,  bugs  in  the  bed  and  on  the  skin). 

The  domain  of  the  free  will  seems  limited  on  account  of  the  weakness  of 
will  and  moral  feeling,  the  rapidity  and  superficiality  of  thought,  the  changed 
feeling,  in  form  and  content,  and  owing  to  imperative  ideas;  and  the  patient 
is  then  very  often  the  plaything  of  moods,  desires,  impulses,  and  fancies.. 
Thus  it  may  happen  that  the  most  important  duties  are  neglected,  the  most 
sacred  sentiments  wounded,  and  the  most  absurd  imaginings  and  motives  are 
obeyed. 

Upon  this  psychoneurotic  and  more  or  less  degenerate  foundation  pro- 
nounced states  of  insanity  naturally  develop.  The  excitability  of  the  emotions 
and  of  the  central  spheres  of  the  senses  and  thought,  as  well  as  the  unstable 
equilibrium  of  the  vasomotor  functions,  predispose  to  this.  Owing  to  the  in- 
fluence of  the  hysteric  character  and  numerous  sensory,  vasomotor,  sexual, 
and  other  functional  disturbances,  which  belong  to  the  general  disease-picture 
of  hysteria  and  undergo  frequent  and  limitless  elaboration  in  delusions,  there 
are  psychic  disease-pictures  whose  origin  in  the  hysteric  neurosis  is  immedi- 
ately evident,  and  which  therefore  must  be  recognized  by  special  pathology  as 
hysteric  insanity. 

As  in  the  case  of  epileptic  insanity,  we  differentiate  the  following 
states  and  disease-pictures: — 

1.  States  of  transitory  insanity. 

2.  Protracted  delirious  states,  analogous  to  the  protracted  psychic 
equivalents. 

3.  Hysteric  psychoses. 

1.  States  of  Transitory  Insanity. 

These  occur  after  convulsive  attacks  of  hj^steria,  as  substitutes 
for  them,  or  as  independent  affections. 

The  special  clinical  picture  is,  owing  to  the  protean  character  of 
the  neurosis,  extremely  variable.    We  observe  with  great  frequency 


494  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

states  of  pathologic  affect,  raptus  melancholicus,  peracute  mania  with 
erotic  and  religious  delusions,  somiuinibulism,  ecstatic  hallucinatory 
delirium  of  religious  erotic  content;  orfthe  content  may  be  frightful, 
and  is  frequently  demonomania^ 

Consciousness  is  here  reduced  to  a  dreamy  state,  and  memory  is 
vanting  or  summary. 

We  observe,  as  prodromes,  globus,  apprehension,  depression,  in- 
creased emotional  irritabilit}',  and  myodynias  in  the  epigastrium. 

The  exciting  causes  are  psychic  impressions,  recrudescence  of 
neuralgias,  and  menstrual  processes. 

These  transitory  psychopathic  states  last  from  some  hours  to  a 
few  days.  They  present  the  features  of  delirium,  for  the  most  part, 
and  are  frequently  complicated  with  tonic  and  clonic  spasms,  which 
may  be  either  hysteric,  hystero-epileptic,  cataleptic,  or  choreiform 
(magna).    Rotable  clinical  varieties  are: — 

(a)  Analogous  to  the  petit  mal  of  the  epileptic :  violent  states 
of  fear  with  disturbance  of  consciousness.  The  patients  are  in  fear 
of  death,  furious,  fear  those  about  them  and  attack  them  in  despair] 
Episodically  there  may  be  errors  of  the  senses — diabolic  forms,  dogs 
that  snap  at  the  patient,  ice-cold  hands  that  wish  to  seize  her,  etc. 
Memory  is  summary. 

(h)  Hystero-epileptic  delirium,  analogous  to  the  grand  mal  of 
the' epileptic.  There  is  unconsciousness.  Memory  afterward  is  want- 
ing. I  The  nucleus  of  the  delirium  usually  consists  of  some  frightful 
event  (violation,  insults,  etc.),  which  originally  caused  the  outbreak 
of  the  disease,  that  is  now  reproduced  in  hallucinations  in  a  dramatic 
and  allegoric  manner. 

The  patients  react  to  these  hallucinations  in  desperate  defense, 
raving,  shouting,  and  striking  about  them.  With  this,  there  are 
choreiform  and  hystero-epileptic  spasmodic  manifestations.^  As  a 
clinical  variety,  which  is  often  observed  in  an  epidemic  f orm,  demono- 
mania  may  be  mentioned^ 

(c)  Ecstatic  visionary  states  analogous  to  those  of  the  epileptic. 
The  patients  here  are  in  a  profound  dreamy  state,  the  nucleus  of 
which  is  extreme  emotionality  thai?  may  reach  the  degree  of  ecstasy 
with  sensations  of  magnetic  currents.  {Upon  this  basis  there  are^de- 
veloped  deliria  of  mystic  union  with  God  or  heavenly  visionsy^  \The 
patients  see  Heaven  open,  preach  with  inspiration,  speak  in  foreign 
tongues,  prophesy,  etc.  At  times  they  may  reach  a  cataleptic  state. 
Memory  is  only  summary. 

(d)  Moria-like  states,  with  singing,  laughing,  dancing,  vociferat- 
ing, gathering  up  objects,  etc.,  which  may  precede  for  some  hours  a 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        495 

liystero-convulsive  attack.     In  the  cases  that  have  come  under  my 
observation  there  was  amnesia  for  what  took  place  in  the  attack. 

(e)  Cloudy  states  of  consciousness  with  imperative  facilitated 
reproduction  of  actual  events  and  what  has  been  read.  The  content 
of  this  logorrheic  delirium  is  mainly  made  up  of  recent  events.  It  is 
a  simple  voluble  reproduction  of  the  events  of  every  day,  but  upon 
the  basis  of  a  dreamy  consciousness  and  with  only  very  summary 
memory  of  them. 

Case  52. — Hysteria.  Ecstatic  states  of  exaltation  associated 
with  frightful  delirious  states. 

F.,  aged  24,  single,  maid.  Her  father  was  a  drunkard  and  her  mother 
suffered  with  migraine.  Several  sisters  and  brothers  died  at  an  early  age  with 
convulsions.  The  patient  was  nearly  made  blind  in  her  early  youth  by  inflam- 
mation of  the  eyes.  She  was  neuropathic,  bright,  and  had  a  very  lively 
imagination.  She  had  lived  for  many  years  in  depressing  circumstances,  and 
she  fell  sick  a  few  months  ago  with  hysteria.  Since  three  weeks  she  presented 
—along  with  marked  globus,  clavus,  and  other  hysteric  symptoms — delirious 
states:  at  times  exalted,  at  times  depressive.  The  former  begin  with  a  feeling 
of  elevation  and  relief.  The  sensorial  sphere  is  so  intensified  in  activity  that 
the  patient  sees  before  her  what  she  tlainks  in  such  lively  colors  that  it  seems 
real.  At  the  same  time  the  pictures  change  with  great  rapidity  and  liveliness. 
The  patient  is  a  simple,  half-blind  peasant  girl,  but  in  these  states  she  seems 
like  an  inspired  clairvoyant.  Her  expression  is  transformed.  Her  movements 
take  place  with  true  grace.  Superb  visions  pass  before  her  eyes.  "The  prince 
of  poets,"  Schiller,  dead  since  many  years,  appears  to  her  in  person  and  talks 
with  her.  He  recites  his  poems  to  her.  Then  she  herself  begins  to  recite  and 
improvise  with  facility  in  verse  what  she  has  read,  experienced,  and  thought. 
Finally  tired,  exhausted  with  headache  and  epigastric  oppression,  she  regains 
consciousness  of  the  real  world,  having  only  summary  memory  for  her  state 
of  blessed  exaltation. 

As  prodromes  or  sequels  of  hystero-epileptic  attacks  there  are  sometimes 
states  of  anxious  delirium  in  which  consciousness  is  veiled,  and  she  is  seized 
with  violent  precordial  distress,  and  sees  ghosts  that  prophesy  disaster,  faces 
of  spirits,  and  caravans  of  monstrous  animals  that  pass  before  her.  At  such 
times  she  feels  unspeakably  unhappy  and  wishes  to  die.  She  is  being  throttled. 
She  sees  her  OAvn  funeral  and  tries,  tortured  by  her  unspeakable  distress,  to 
choke  herself,  and  rushes  restlessly  and  dreamily  about.  Usually  the  scene 
ends  by  an  hystero-epileptic  attack,  from  which  she  emerges  unspeakably 
miserable,  profoundly  exhausted,  with  globus  and  urina  spastica.  There  are 
numerous  hysteric  symptoms  during  the  intervals. 

Case  53. — Hysteric  states  of  exaltation,  with  imperative  and 
facilitated  reproduction. 

W.,  daughter  of  an  official,  aged  16.  Her  father  was  choleric  and  of 
abnormal  character.  Childhood  and  puberty  passed  without  notable  symp- 
toms. 


496  SPECL\L  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  family  met  with  financial  misfortune  a  few  months  ago.  The  patient 
had  much  care,  ate  iusufliciently,  and  overworked  at  sewing.  She  began  to 
feel  ill,  to  sleep  badly,  complain  of  exhaustion,  nervous  excitement,  palpitation. 

On  January  19,  1S7S,  shortly  after  menstruation,  there  were  several  days 
of  sleeplessness  and  nervous  excitement,  which  led  up  to  an  attack  of  halluci- 
natory deliriiun,  and  which  was  repeated  on  the  20th  from  9  o'clock  in  the 
morning  till  2  in  the  afternoon,  and  from  4  in  the  afternoon  till  5.30.  The 
immediate  prodromes  were  feeling  of  pressure  in  the  cardiac  region,  with  ap- 
prehension, lluxion  to  the  head,  and  dizziness.  On  February  10th,  again  after 
the  menses,  the  attack  recurred.  It  was  preceded  by  a  feeling  of  stillness  in 
the  arms,  which  spread  over  the  Avhole  body.  Then  there  were  violent  con- 
gestion of  the  head,  dizziness,  clouding  of  consciousness,  slight  twitchings  in 
the  extremities,  and  hallucinations.  The  patient  heard  bells,  birds  chirping, 
and  saw  fire.  ^\'ith  increase  of  the  muscular  twitchings  and  constant  restless- 
ness, there  was  a  peculiar  state  of  exaltation  with  imperative,  but  facilitated, 
reproduction  of  what  had  been  heard,  experienced,  or  read.  The  intensifica- 
tion of  memory  was  so  great  that  the  patient  was  able  to  reproduce  a  poem  of 
over  two  pages  which  she  had  read  a  short  time  before.  Such  attacks  lasted 
several  hours  and  recurred  twice  on  the  following  days.  Since  this  time  the 
patient  was  nervous,  much  excited,  had  a  tendency  to  fluxions,  was  very 
sensitive  to  light  and  noises,  and  with  very  excitable  imagination,  so  that  she 
could  not  distinguish  between  what  was  read  and  what  was  actual,  and  when 
reading  exciting  novels  fell  into  a  peculiar  ecstatic  cataleptic  state  in  which 
she  had  only  confused  impressions  of  the  external  world,  and  was  in  a  state  of 
clouded  consciousness  with  general  muscular  stiffness. 

The  patient  was  of  "mediimi  height,  delicate,  fully  developed,  of  neuro- 
pathic facial  expression  with  swinmiing  eyes.  Uterus  virginal,  slightly  en- 
larged, inclined  to  the  right.  Thereafter  there  were  palpitation,  unstable 
vasomotor  innervation,  pulse  varying  in  frequency,  abnormal  flushing,  frequent 
terrors  at  night.  On  one  occasion  fainting  attack  preceded  by  vascular  spasm. 
Potassium  bromide,  hydrotherapy,  and  tonic  treatment  had  a  favorable  effect. 
The  states  of  exaltation  and  convulsive  symptoms  did  not  return. 

Case  54. — Hysteria  after  violation.  Attacks  of  113'stero-epilep- 
tic.  frightful  hallucinatory  delirium. 

L.  L.,  aged  18,  servant,  without  hereditary  predisposition  to  nervous  dis- 
ease, formerly  healthy.  Before  menstruation  had  occurred,  at  the  age  of  14 
she  was  the  victim  of  an  attack  on  the  part  of  her  adopted  father.  After 
recovering  from  her  first  fright,  she  felt  uncomfortable.  It  seemed  as  though 
she  was  going  to  be  very  ill.  She  complained  of  fatigue;  felt  incapable  of 
work.  With  this  there  was  lieadache  and  troublesome  pressure  over  the  heart. 
Admitted  into  the  children's  hospital  at  Strassburg.  Discharged  improved 
after  a  few  weeks. 

Her  improvement  did  not  last.  The  original  indefinite  disturbance  of  the 
nervous  system  due  to  the  psychic  shock  developed  into  a  state  of  hysteria 
(vague  neuralgic  pains,  especially  in  the  intercostal  nerves;  myodjTiias; 
globus,  with  exacerbations  of  which  the  mood  always  became  depressed,  and 
there  developed  marked  emotional  irritability).  During  the  course  there  were 
attacks  of  partial  clonic  spasms  with  loss  of  consciousness.    At  17  hystero- 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        497 

epilepsy  (general  clonic  convulsions  with  loss  of  consciousness) ;  at  18  psychic 
disturbances  were  added  to  the  disease-picture.  There  was  great  and  causeless 
change  of  feeling.  With  these  states  of  psychic  depression  there  was  pre- 
cordial distress  at  the  height  of  which  twdium  vitw  and  destructive  impulses 
occurred.  At  such  times  she  tore  her  clothing,  demanded  a  knife  to  kill  her- 
self, wished  to  drown  herself,  and  made,  on  one  occasion,  a  suicidal  attempt. 
In  the  course,  hallucinations  of  hearing  and  sight.  She  heard  speaking  in  her 
sleep;  she  heard  voices  that  told  lier  she  would  have  a  child;  with  this, 
visions  of  her  adopted  father,  who  attempted  to  repeat  his  crime.  At  the  same 
time,  complaint  of  difficulty  of  thought,  loss  of  memory,  confusion  in  the 
head.  On  admission  to  the  emergency  hospital  in  the  beginning  of  October, 
1872,  general  hyperesthesia,  which  expressed  itself  in  numerous  neuralgias  and 
myodynias,  together  with  symptoms  of  reduced  sensibility  (formication  from 
the  neck  to  the  ends  of  the  fingers,  increased  cerebral  and  spinal  reflex  excita- 
bility). Reflex  contractions  on  touching  certain  neuralgic  points,  that  increase 
to  general  trembling  and  weakness;  causeless  changes  of  feeling  and  sensation 
of  confusion  in  the  head;  imperative  fixity  of  certain  ideas  in  relation  to  dis- 
ease; hallucinations  of  sight  and  hearing.  Now  and  then  there  are  delirious 
attacks  lasting  from  half  an  hour  to  two  hours,  always  induced  by  hallucina- 
tory visions  of  the  adopted  father  who  attempts  to  repeat  his  crime.  Symp- 
toms of  increased  reflex  excitability  (partial  convulsions,  general  tremor  at  the 
slightest  noise)  precede.  The  attacks  show  the  character  of  hallucinatory  de- 
lirium, which  is  made  up  of  an  hallucination  of  violation  and  efforts  to  pre- 
vent it.  Consciousness  is  lost.  The  patient  starts  in  fright,  defends  herself 
in  despair;  movements  are  co-ordinated;  occasionally  there  are  finally  reflex 
spasms  (tonic  and  clonic  convulsions),  with  spasmodic  rolling  of  the  eyes  and 
grinding  of  the  teeth.  After  an  attack  lasting  from  half  an  hour  to  two  hours 
the  patient  comes  out  of  it  with  dull  headache,  dizziness,  great  lassitude,  pain- 
ful myodynias,  gi^eat  irritability,  and  complete  amnesia  for  the  time  of  the 
attack.  During  several  months  of  observation,  the  condition  did  not  change, 
which  indicated  an  unfavorable  prognosis. 

2.  Pkotkacted  States  of  Hysteeic  Delirium. 

In  the  hysteric  there  are,  not  infrequently,  states  of  delirium 
that  arise  essentially  out  of  numerous  hallucinations,  and  Avhich, 
owing  to  the  marked  clouding  of  consciousness,  do  not  lead  to  sys- 
tematization,  even  though  some  combinations  of  delusions  and  alle- 
goric interpretation  of  hysteric  sensations  do  occur. 

Such  abnormal  states  might  be  called  hysteric  hallucinatory  in- 
sanity. Many  cases  may  also  be  considered  as  protracted,  or  fre- 
quently relapsing  attacks,  of  the  transitory  insanity  of  the  hysteric 
previously  described,  and  can  be  compared  with  the  similar  states  of 
epileptics,  in  so  far  as  the  pictures  of  petit  and  grand  mal  and  those 
of  ecstatic  visionary  delirium  upon  an  hysteric  basis,  either  terminat- 
ing or  complicating  it,  make  up  the  disease-picture.  These  hysteric, 
delirious,  protracted  states  begin  acutely,  disappear  suddenly,  last 
from  weeks  to  months^  and  have  a  pronounced  exacerbating  and  re- 


498  SPECIAL  PATHOLOGY  AXD  THERAPY  OF  INSANITY. 

mitting  course  that  may  extend  to  phases  of  relative  lucidit}',  and 
are  ahvays  accompanied,  during  the  exacerbation,  by  a  marked  dis- 
turbance of  consciousness,  \vhich,  as  incoherence  and  states  of  chiuded 
consciousness,  may  be  intensified  to  the  degree  of  ecstasy  and  stupor. 
It  is  only  rarely  that  they  are  added  to  severe  hysteric  attacks  and 
appear  in  -the  course  of  these.  On  the  contrary,  it  is  in  the  milder 
cases  of  hysteria  that  such  delirious  conditions  .occur;  except  occa- 
sional spasmodic  stiffness,  I  have  never  seen,  in  the  course  of  this 
delirious  condition,  severe  manifestations  of  hj'steria. 

Protracted  hysteric  delirium  depends  upon  temporary  exhaus- 
tion. It  develops  after  or  in  connection  with  profuse  menstruation, 
during  the  puerperal  state,  and  with  especial  frequency  in  the  climac- 
teric. Emotional  disturbances  seem  to  favor  its  outbreak.  It  is 
prone  to  relapse,  but  in  eighteen  cases  that  came  under  my  observa- 
tion it  ended  in  recovery. 

The  delirium  presents  a  mixture  of  the  most  various  primordial 
delusions  (persecutor}'-,  of  sin,  sexual,  religious).  Most  frequently  we 
find  delusions  of  persecution,  with  often  very  violent  reaction,  and 
then,  in  order,  come  religious  and  erotic  delusions.  Plallucinations 
of  all  the  senses  are  not  infrequent.  The  most  frequent  and  impor- 
tant are  visual,  olfactory,  and  sensory  errors.  The  visual  hallucina- 
tions are  very  frequently  of  animals,  funerals,  fantastic  processions, 
in  which  there  are  indications  of  the  dead,  devils,  ghosts,  etc.  The 
illusions  of  sight  consist  of  continual  transformation  of  the  faces  and 
persons  of  those  about  into  masks,  animals,  and  of  changes  of  color. 
The  errors  of  hearing  are  simply  noises  in  the  ear  (cries,  loud  noises, 
detonations)  or  actual  hallucinations,  often  of  sexual  content  (pro- 
posal of  marriage,  obscene  insults,  accusation  of  child-murder)..  The 
olfactory  hallucinations  are  of  the  odor  of  sulphur,  tobacco,  etc.,  and 
less  frequently  they  are  of  a  pleasant  character  (incense,  perfume  of 
roses,  etc.). 

The  significance  of  this  condition  as  hysteropathic  depends  upon 
the  peculiar  content  of  the  visual  hallucinations  and  illusions;  upon 
the  prominence  of  sexual  delirium,  and  the  accompanying  hysteric 
sensations  and  symptoms,  which  frequently  undergo  allegoric  delir- 
ious elaboration  in  the  disturbed  consciousness;  upon  the  episodic 
manifestation  of  spasm,  laughing,  weeping,  ecstasy,  etc. 

As  to  treatment,  reference  to  the  treatment  of  hallucinatory 
.  insanity  will  suffice. 

Case  55. — Hysteric  protracted  hallucinatory  delirium. 

]\Iiss  E..  aged  25,  comes  of  a  tainted  family.  She  was  a  delicate,  talented, 
very  excitable,  choleric  child,  and  as  a  young  girl  enthusiastic,  intensely  ideal- 


MENTAL  DISEASE  FROM  CONST  [TUTION AL  NEUROSP:S.        490 

istic;  but  she  changed  to  the  other  extreme  in  her  twentieth  year.  She  was 
always  very  emotional,  and  reacted  under  emotional  excitement  with  fever 
and  hallucinations.  In  1875  she  had  diphtheria,  and  thereafter  was  neuras- 
thenic. Owing  to  emotional  shock  due  to  a  death  in  her  family,  and  owing  to 
the  sickness  of  her  tabetic  father,  her  neurasthenic  condition  grew  worse  and 
spinal  irritation  was  added.  In  the  beginning  of  March  the  patient  slipped 
and  fell  lightly  on  her  back,  but  she  was  violently  frightened  by  the  fall. 
Thereafter  hysteria  developed.  She  had  headache,  pain  in  the  back,  inter- 
costal neuralgia,  ice-cold  feet,  globus,  feeling  of  floating  in  the  air,  optic  hyper- 
esthesia (seeing  sparks  and  flames),  felt  electric  shocks  that  went  irony  the 
back  to  the  head.  She  had  attacks  of  crying  and  of  fear.  In  July  general 
cutaneous  hyperesthesia  was  added.  When  the  surface  of  the  body  was  wet  it 
nauseated  her,  and  pressure  on  the  head  induced  attacks  of  weeping.  Then 
came  feelings  of  heat  and  cold,  sensations  as  if  the  spinal  column  were  dry  and 
as  if  there  were  sand  between  the  ribs.  During  July  tra'nsitory  clonic  spasms 
and  spasmodic  stiffness,  with  conditions  of  aphasia.  She  saw  everything 
green-yellow,  the  faces  of  the  people  distorted  and  in  various  colors.  The  fur- 
niture seemed  lengthened.  No  natural  sleep  since  the  beginning  of  June,  but 
the  family  physician  had  used  much  chloral  for  sleep,  so  that  when  the  patient 
came  under  my  treatment  she  was  completely  edematous. 

On  July  20th  hallucinations  of  all  the  senses  came  on,  and  with  this  a 
delirious  state,  which  made  it  necessary  to  put  her  in  the  asylum  in  the  middle 
of  August.  The  patient  stated  that  she  was  magnetized,  that  she  was  preg- 
nant, that  she  saw  innumerable  spiders,  bugs,  snakes,  heard  sexual  accusa- 
tions, smelled  bad  odors;  she  said  she  was  a  toad,  that  the  nurse  was  the 
Wandering  Jew,  that  her  head  and  brain  were  double,  and  that  the  saliva 
came  from  her  brain;  that  she  was  syphilitic,  and  wished -to  be  shot  and 
buried. 

There  were  no  physical  findings  on  her  admission  except  marked  anemia, 
edema  of  the  face,  and  great  loss  of  weight.  The  patient  is  extremely  con- 
fused, given  up  entirely  to  errors  of  the  senses,  and  quite  unconscious  of  her 
position.  The  physician  is  King  John,  the  nurses  are  princesses.  She  takes 
the  physician  for  her  husband,  arranges  the  marriage  bed,  undresses.  She 
hears  her  supposed  husband  in  the  cellar  calling  for  help,  says  that  he  is  being 
poisoned  by  her  sisters;  wishes  to  cut  off  her  nose  because  the  voices  say  she 
can  thus  save  him.  She  notices  worms  in  her  food  and  in  the  bed.  They 
come  through  her  toes.  She  hears  innumerable  voices  which  constantly  inter- 
rupt her  thought  and  drive  her  to  distorted  acts,  such  as  eating  spiders  and 
earthworms.  Now  and  then  disagreeable  taste  of  ink,  odors  of  dead  animals, 
visions  of  corpses  and  frightful  animals. 

At  the  time  of  the  menses,  predominance  of  sexual  delusions  of  violation, 
infamous  accusations,  and  increased  disagreeable  odors.  At  the  same  time, 
numerous  paralgias,  myodynias,  intercostal  neuralgias,  feelings  as  if  the  head 
were  split  and  water  poured  into  the  brain — everything  is  done  to  her  by 
means  of  electricity  and  magnetism. 

With  good  food  and  care,  iron,  potassium  bromide  up  to  6  grams  daily 
and  occasional  injections  of  morphine,  the  patient  improved  during  the  course 
of  November,  both  physically  and  mentally.  The  hysteric  symptoms  and  the 
errors  of  the  senses  became  less  frequent.  Consciousness  became  clear  by  the 
end  of  December.     At  the  time  of  the  menses,  exacerbations.     Patient  hears 


500  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY.      . 

again  several  voices  talking  of  sexual  tilings  and  persecution.  They  told  her 
slie  must  enter  a  convent  in  order  to  save  her  sisters;  that  she  uould  remain 
here  in  prison  all  her  life.  At  the  connnand  of  a  voice,  siie  sprang  out  of  a 
lirst-story  window  without  injuring  herself. 

During  the  course  of  January,  she  improved  slowly.  The  patient  was 
slill  mentally  exhausted  and  neurasthenic,  but  free  from  delirium  and  halluci- 
nations since  February.  She  was  sent  home  convalescent .  and  recovered  dur- 
ing the  following  sunnner,  excejit  for  slight  hysteric  symptoms. 

3.  ]1ysti:ric  rsYciiosi:s. 

These  disoase-pielures  peniiit  quite  a  definite  sojtaration  of  those 
that  depend  upon  a  simple,  non-constitutional  acquired  hysteric  neu- 
rosis and  those  that  represent  a  transitional  stage,  or  episodic  condi- 
tion, in  hysteric  degeneration. 

In  the  first  case  we  have  to  deal  with  psychoneu roses  (melan- 
cholia, mania)  that  have  a  favorable  prognosis,  and  which  differ  from 
corresponding  iion-hysteric  cases  only  in  their  shorter  course  in  gen- 
eral and  the  mixture  and  allegoric  interpretation  of  symptoms  of  the 
hysteric  neuroses. 

Melancholia  dependent  upon  a"n  liysteric  foundation  seems  dis- 
tinguished by  predominance  of  precordial  distress,  frequency  of 
raptus  melancholicus,  tendency  to  suicide,  and  the  frequent  elabora- 
tion of  hysteric  sensations  (especially  globus,  neuralgias,  myodynias) ; 
by  delusions  that  frequently  have  a  demoniac  coloring,  with  very 
frequent  hallucinations  of  sight,  and  the  theatric  expression  of  the 
depressive  emotional  state,  in  which  a  certain  coquetting  with  suf- 
fering and' pain  is  to  be  noticed. 

Mania  seems  to  me  remarkable  for  the  absence  of  the  melan- 
cholic prodromal  stage,  the  subacute  course,  the  great  change  of 
feeling,  and  especially  the  great  instability  of  mood  and  predominance 
of  erotic  religious  delusions. 

Quite  different  is  the  psychosis  upon  hysteric  foundation  when 
it  is  a  phase  of  progressive  functional  degeneration,  which,  dependent 
upon  a  constitutional  and  usually  hereditary  predisposition,  arises  at 
the  time  of  puberty,  takes  on  severer  forms,  and  undergoes  trans- 
formations, especially  to  that  of  hystero-epilepsy,  and,  unnoticed, 
progresses  to  mental  disturbance.  The  disease-pictures  under  such 
circumstances  are  those  of  the  degenerate  forms, — folie  raisonnanle, 
moral  insanity,  especially  paranoia  and  also  uninterrupted  progress- 
ive dementia. 

Paranoia  takes  on  a  persecutory  form,  or  it  is  erotic  or  religious. 
The  laws  of  its  course  are  the  same  as  those  of  other  cases  upon  a 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        501 

different  foundation.  The  persecutory  form  frequently  presents 
transformation  of  the  delusions  (religiouS;,  erotic  delusions). 

Hysteria  predisposes  to  paranoia,  and  especially  to  the  form 
characterized  by  delusions  of  persecution,  because  in  the  sensitive 
patients  the  feeling  of  being  neglected  and  disregarded  easily  arises; 
because  the  central  sensorial  sphere  is  easily  ex'cited  to  hallucina- 
tion; and  because  the  creations  of  the  imagination  and  hallucina- 
tions, owing  to  the  functional  weakness,  are  with  difficulty  corrected 
by  the  higher  intellectual  activities.  With  this,  when  the  disease  is 
advanced,  there  takes  place  in  consciousness  unlimited  direct  trans- 
formation of  sensations  into  delusions;  and  also  accompanying  sen- 
sations, which  may  reach  the  intensity  of  hallucinations,  easily  occur, 
owing  to  the  great  excitability  and  intensity  of  ideation. 

The  peculiar  clinical  features  of  paranoia  upon  hysteric  founda- 
tion are: — 

1.  Unlimited  interpretation  of  hysteric  sensations  in  the  sense 
of  corresponding  allegoric  delusions  (globus,  clavus,  myodynias,  neu- 
ralgias, paralgias,  visceralgias,  spinal  irritation — interpreted  as  perse- 
cution, usually  of  a  physical  or  electro-magnetic  nature;  muscular 
anesthesias — ^interpreted  as  floating,  as  abnormal  lightness;  in  com- 
bination with  cutaneous  anesthesia,  visceral  anesthesia — interpreted 
as  removal  of  organs,  etc.). 

2.  The  frequency  of  visual  hallucinations,  as  compared  with 
other  forms  of  paranoia  devoid  of  hysteric  basis  (animals,  death, 
corpses,  play  of  color,  etc.). 

3.  The  frequency  with  which  the  delusions  follow  delirious 
episodic  states  that  are  specifically  hysteric.  The  development  of 
the  disease  under  such  circumstances  is  sudden  out  of  such  transitory 
delirium. 

4.  The  predominating  implication  of  the  sexual  sphere.  This 
influence  may  be  direct  and  organic,  in  that  genital  irritative  proc- 
esses may  induce  in  the  organ  of  consciousness  erotic  (persecutory  or 
expansive)  and  religious  delusions;  or,  when  this  influence  is  con- 
sciously recognized,  it  may  undergo  allegoric  interpretation. 

Cerebro-spinal  sensations'  derived  from  the  uterus,  usually  hy- 
peresthesias and  neuralgias,  are  interpreted  in  a  persecutory  sense 
(magnetic-electric).  The  genital  sensory  anomalies  are  interpreted 
as  pregnancy,  as  relations  with  divine  persons,  or  as  violation. 
Clearly  the  incubus  and  succubus  of  former  times,  with  their 
demoniac  relations,  are  to  be  referred  to  this  source.  Even  to-day, 
the  complaints  of  hysteric  paranoiac  women  in  insane  as^dums  of 
nightly  violation  are  quite  usual.    By  reflex  uterine  stimulation  of 


502  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tlie  optic  and  auditory  centers,  corresponding  hallucinations  are 
frequently  observed  (sexually  insulting  and  pleasing  voices,  obscene 
and  religious  visicuis) ;  but  similar  hallucinations  are  es])ecially 
frequent  in  the  olTactory  domain.  The  content  of  olfactory  hal- 
lucinations is,  for  tlie  most  part,  un])leasant — foul  odors,  sweat  as 
the  object  of  disgust  on  the  part  of  others,  or  as  signs  of  persecution 
by  them  (with  intci'pretation  of  feelings  of  nnmhiu'ss.  fainting  spells, 
etc.);  infrequently  olfactory  hallucinations  are  })h'asant  (in  I'eligions 
paranoia,  the  odor  of  flowers,  incense,  etc.). 

With  the  oncoming  of  paranoia,  usually  the  severe  somatic 
symptoms  of  hysteria,  especially  convulsions,  diminish. 

The  ecstatic  and  even  cataleptic  states  very  frequently  accom- 
pany the  further  course  of  erotic  and  religious  paranoia.  The  malady 
shows  a  tendency  to  long  remissions  and  even  to  intermissions.  At 
the  height  of  the  disease  exacerbations  are  almost  always  associated 
with  menstrual  processes. 

The  prognosis  is  unfavorable.  Potassium  bromide  and  morphine 
usuall}''  ameliorate  the  sensations  and  states  of  excitement  arising 
from  the  uterine  nervous  system,  and  quiet  the  patients. 

Case  56. — Original  paranoia  on  an  hysteric  basis.  Transforma- 
tion through  hysteric  delirious  states. 

Marie  W.,  aged  42,  single.  Father  was  a  drunkard;  mother  was  very 
choleric,  having  had  several  attacks  of  insanity.  Several  brothers  and  sisters 
died  of  convulsions.  The  patient  was  found  near  Gratz  in  a  cave,  where  she 
had  gone  because  she  felt  hurt  tliat  no  one  liad  given  her  recognition  and 
sympathy. 

From  childhood  she  was  neuropathic,  suffered  much  with  headache,  felt 
that  she  was  not  treated  like  the  other  children,  and  put  aside  by  her 
parents.  She  soon  began  to  think  that  tliey  were  not  her  real  parents.  In 
her  fourth  year  an  unknown  gentleman  on  the  street  asked  her  in  joke  if 
she  did  not  wish  to  be  his  daughter.  This  made  a  profound  impression  on  her. 
When  she  came  home  her  mother  whipped  her  and  smashed  her  nose  in  order 
to  make  her  unrecognizable.  Then  she  was  very  sorry  that  she  had  not  gone 
with  the  gentleman.  She  became  so  moody  and  depressed  that  she  thought  of 
ending  her  life  by  drowning.  It  is  said  that  the  menses  began  at  the  age  of  8, 
disappeared  for  two  years,  and  thereafter  recur i-ed  irregularly,  and  always 
Avith  pain  in  the  abdomen  and  back.  On  their  first  appearance  the  patient  had 
felt  pecidiar  anxiety,  numbness,  desire  to  sleep,  and  fatigiie.  \Ylxile  slie  was 
still  going  to  school  she  once  met  a  strange  family  that  was  passing  the 
summer  in  the  A'illage.  The  lady  was  friendly  to  her,  and  even  made  her 
presents.  She  felt  drawn  to  her,  and  it  seemed  to  her  that  she  was  her  real 
mother.  ' 

In  her  thirty-third  j'ear  the  actual  disease  began.  The  patient  at  that 
time  Avas  suffering  with  hysteria  (globus,  hyperesthesias,  etc.).  She  began  to 
notice  that  people  spoke  incomprehensibly,  that  everybody  looked  at  her,  and 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        503 

that  all  were  cruel  and  murderous  in  their  attitude  toward  her.  They  tried  to 
poison  her.  She  knew  this  because  her  abdomen  became  so  bloated  (hysteric 
meteorism). 

In  her  thirty-fourth  year  it  was  revealed  to  her  (hallucination)  that 
her  so-called  parents  were  not  her  parents.  After  that  she  called  them  only 
foster-parents.  For  a  long  time  her  lack  of  resemblance  to  her  brothers  and 
sisters  had  struck  her.  Now  it  was  also  clear  why  she  had  always  been  the 
Cinderella  in  the  house.  It  was  also  brought  to  her  knowledge  that  in  her 
first  year  she  had  been  stolen  from  her  parents  by  a  band  of  Jews.  She  had 
later  come  to  recognize  this  band  by  the  sense  of  smell.  In  the  beginning  of 
the  disease  evidently  there  were  hallucinatory,  delirious  hysteric  states  which 
led  to  the  further  development  of  delusions.  Thus  she  lay  in  a  sea  of  fire,  and 
later  in  a  tomb.  She  knew  this  by  the  odor  of  corpses.  On  coming  out  of  a 
lethargic  state  she  heard  some  one  ask  whether  she  were  living  or  dead.  She 
had  said  that  she  was  living.  She  heard  then  another  voice  telling  her  to  feel 
on  her  head.  She  noticed  that  there  was  a  crown  there,  but  she  was  unable 
to  speak.  She  noticed  also  that  an  attempt  had  been  made  to  poison  her  in 
order  to  conceal  her  high  position  and  steal  her  inheritance. 

In  another  psychic  exceptional  state  she  once  heard  the  words  "royal 
beast"  and  noticed  that  this  curse  was , directed  against  her  and  the  archducal 
family.  In  later  delirious  states  matrimony  had  been  proposed  to  her.  She 
saw  no  one  present  at  the  ceremony,  but  she  heard  everything.  She  was 
made  to  sit  up  in  bed  and  forced  to  say  yes,  the  first  time  in  a  promise  to  a 
certain  W. ;  a  second  time  to  the  emperor;  a  third  time  her  voice  deserted 
her.  She  also  read  about  this  in  the  newspapers,  but  usually  in  doing  this  it 
grew  black  before  her  eyes;  however,  on  another  occasion,  as  she  looked 
more  intently  at  the  newspaper,  she  saw  it  there  in  golden  letters.  In  her 
hysteric  sleep  and  states  of  catalepsy  she  had  been  violated  and  made  preg- 
nant. She  had  had,  however,  one  (actual),  two  small  (abortions),  and  three 
large  confinements  (imaginary).  The  latter  had  been  concealed  by  stealing  the 
children.  She  had  been  treated  in  a  hostile  way  by  everybody.  It  was  par- 
ticularly her  tyrannic  foster-mother  Avho  had  struck  her,  tramped  on  her,  torn 
off  the  end  of  her  nose,  and  rendered  her  thus  imrecognizable  and  so  different 
from  her  noble  and  legitimate  mother.  She  now  looked  quite  different;  her 
sleep  was  strange  and  no  longer  refreshed  her.  Until  lately  she  had  been 
persecuted,  pushed  aside,  although  in  reality  she  should  have  the  highest  place 
in  Gratz.  It  Avas  only  in  her  last  service  that  the  lady  had  been  kind  and 
good.  She  noticed  from  her  resemblance  to  this  lady  that  she  was  her  actual 
mother.  She  had  noticed  all  the  conversation  referring  to  the  lady  while  in 
her  home,  and  had  found  that  her  real  mother  was  named  "Full  Moon,  Glad 
Sultan"  and  that  she  was  really  a  queen.  At  this  place  she  also  often  felt  a 
crown  on  her  head;  but  Avhen  she  reached  for  it  at  the  command  of  voices  the 
crown  had  been  taken  away. 

The  patient  is  of  medium  height,  of  brachycephalic  skull.  The  broad 
root  of  the  nose  lies  deep  and  seems  to  be  pressed  in.  The  right  ear  is  smaller 
than  the  left.  The  patient  suffers  with  numerous  hysteric  symptoms,  which 
occur  especially  at  the  time  of  the  menses.  Her  manner  is  that  of  proud 
reserve.  She  lives  entirely  in  her  romantic,  persecutory,  and  grand  ideas, 
which  she  reveals  only  while  in  affects.  The  disease-picture  is  absolutely 
stationary. 


504  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Case  57. — Hj'steric  paranoia  (sensations). 

H.,  aged  39,  widow  of  an  ofTicial,  admitted  October  7,  1875.  She  is  said  to 
have  no  hereditarj'  predisposition.  A  sister  subject  to  spasms.  In  her  fif- 
teenth year,  with  the  beginning  of  puberty,  the  patient  became  chlorotic  and 
hj'steric.  Traces  of  the  hysteric  neurosis  can  be  discovered  through  the  whole 
of  her  life  since  that  period.  The  patient  was  married,  but  never  cohabited. 
Three  years  ago  the  patient  became  suspicious  and  thought  tliat  she  was 
watched,  maligned,  and  despised  on  A^arious  sides.  She  hid  her  money,  and  she 
was  told  at  night  where  she  had  hid  it.  She  noticed  disai:)pearance  of  money 
and  valuable  papers.  Her  food  was  poisoned  and  parts  of  her  limbs  were  re- 
moved (temporary  anesthesia).  She  moved  from  one  house  to  another,  and 
was  always  in  quarrels  with  her  neighbors,  to  whom  she  attributed  her  perse- 
cution. Two  years  ago  numerous  hysteric  sensations  and  hallucinations  came 
on,  the  location  and  content  of  which  clearly  indicated  excitation  in  the  gen- 
ital system.  She  was  called  harlot,  obscene  proposals  were  made  to  her,  and 
her  strength  was  sucked  away  from  her.  The  peculiar  designation  which  the 
patient  gave  to  her  various  sensations,  partly  dependent  upon  tho  formation 
of  new  words,  is  interesting.  All  her  troubles  are  brought  about  by  a  secret 
force  which  she  called  cc/'f-  She  describes  the  mode  of  her  sensations  by  add- 
ing the  syllable  cc//  to  the  name  of  the  organ  in  which  she  has  the  sensation 
(larynx-,  liver-,  stomach-  zeif,  etc.).  Among  other  troublesome  sensations 
there  was  the  feeling  of  having  her  strength  sucked  out  through  the  anus,  the 
sacrum,  and  the  vagina.  This  occurs  only  occasionally,  but  it  goes  on  until 
she  is  benumbed,  as  if  drunk,  and  cannot  see.  Her  anus  is  absolutely  de- 
stroyed. There  is  always  a  sensation  there  (stretching  of  the  anus).  The 
sucking  in  the  vagina  has  existed  since  she  was  examined  by  the  physician. 
This  sensation  of  sucking  is  very  unpleasant;  and  even  when  she  does  not  feel 
it  her  genitals  are  painful. 

Sometimes  there  is  a  sucking  sensation  in  the  head  and  the  stomach. 
The  thoughts  are  sucked  out  of  her  head.  This  is  easy,  because  her  whole 
head  is  open.  When  there  is  sucking,  she  feels  a  painful  drawing  in  the  head. 
This  process  is  kept  up  until  she  is  absolutely  worn  out.  Whenever  the 
nurses  go  out,  they  suck  all  her  juices  out  in  order  to  commit  debauches  in 
town. 

She  is  all  filled  with  acrid  vapors,  and  describes  this  feeling  "as  if  poison 
were  breathed  into  her  through  the  walls."  Through  the  wall  she  is  aspirated 
in  the  sacral  region.  Her  heart  is  cut  to  pieces,  her  head  is  split  (congestion), 
and  her  brain  is  drawn  out  through  the  nose  (occasional  cold).  Slie  is  cut, 
stabbed,  and  drawn  on  in  the  loins  and  hips  (intercostal  neuralgia). 

Her  thoughts  are  drawn  out  of  her,  and  because,  in  this  she  experiences 
a  pricking,  boiling  feeling  in  the  scalp,  she  calls  this  procedure  dackensud. 
The  same  process  is  carried  on  with  her  head  (daJcen):  i.e.,  it  is  used  for  mental 
work  by  others,  a  process  which  she  calls  "doctoring."  She  is  also  subject  to 
tendendengs:   i.e.,  other  thoughts  are  put  into  her  head. 

An  especially  unpleasant  sensation  is  that  of  the  crawling  of  ants  along 
the  back,  which  begins  in  the  hair  at  the  back  of  the  head  and  descends.  She 
therefore  calls  it  hairdack.  She  also  feels  shaking  and  trembling  in  the  whole 
body.  She  is  then  durchgereift.  Sometimes  she  is  made  dead  temporarily 
throughout  the  right  side.  She  has  crabs  in  the  body,  which  eat  up  everything 
in  her.     She  is  purely  the  object  of  low  joking. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        50 5 

With  these  hysteric  sensations  that  are  interpreted  in  the  paranoiac 
sense  there  are  also  numerous  hallucinations  which  of  late  years  have  taken 
on  more  and  more  a  sexual  coloring.  She  hears  sexual  insulting  words.  Those 
around  her  evidently  have  tongue-  and  tooth-  zeif.  The  patient  hears  her 
thoughts  spoken  aloud.  She  is  called  secretly  "harlot";  the  nurses  say  that 
she  is  probably  a  papess  enceinte  since  a  long  time.  She  is  the  object  of 
shadow-play.  At  night  her  vagina  is  fussed  with.  She  is  overshadowed  by 
the  bishop,  who  throws  a  cloth  over  her  face  at  night.  Olfactory  hallucina- 
tions also  are  not  wanting.  Foul  odors  are  driven  through  the  walls  into  her 
nose. 

As  reaction  to  this  misery  the  patient  is  almost  constantly  in  unre- 
strained, angry  excitement  that  leads  to  acts  of  violence  toward  those  around 
her,  from  whom  all  is  derived.  At  the  time  of  the  menses,  when  sensations 
and  hallucinations  are  intensified,  the  patient  is  especially  excited  and  also 
sleepless.  It  is  only  possible  to  occupy  her  and  distract  her  temporarily. 
Potassium  bromide  and  injections  of  morphine  have  only  temporary  effect. 
Aside  from  the  severe  hysteria,  the  most  careful  examination  reveals  nothing 
besides  chronic  uterine  and  vaginal  catarrh  with  abundant  leucorrhea,  condi- 
tions which  certainly  were  very  important  from  an  etiologio  standpoint. 
Gynecologic  treatment  could  not  be  carried  out  with  the  patient. 


CHAPTER  IV. 
Hypochondriac  Insanity. 

The  discussion  as  to  Avhether  hypochondria  should  be  reckoned 
as  a  neurosis  or  a  psychosis  should  be,  all  things  considered,  decided 
in  favor  of  the  latter  assumption.  Concerning  the  place  of  hypo- 
chondria in  the  psychoses,  there  are  differences  of  opinion.  Grie- 
singer  regards  it  as  a  mild  form  of  melancholia.  Actually,  psychic 
pain  and  signs  of  inhibition  are  observed  in  the  hypochondriac;  but 
they  are  not  primary,  rather  secondary  manifestations — a  reaction 
to  troublesome  general  sensations,  paralgias,  etc.;  and  out  of  these 
develop  apprehensive  ideas  which,  like  imperative  ideas,  do  not 
permit  others  to  rise,  and  they  force  the  patients  continually  to 
occupy  themselves  with  the  disturbed  processes  taking  place  in  their 
bodies. 

This  forced  preoccupation  is  explained  in  part  by  the  physio- 
logic influence  of  the  mode  and  manner  of  bodily  feelings  (general 
feeling)  upon  emotion  and  idea;  in  part,  by  the  content  of  the  ideas 
which  fill  consciousness,  in  that  they  are  concerned  with  serious  dis- 
ease and  danger  to  life.  Essentially,  hj^pochondria  may  be  called 
a  sensory  neurosis  (neurosis  of  general  feeling),  with  reactional  im- 
plication of  the  psychic  sphere,  which  is  never  wanting.     If  tern- 


506  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

porarily  consciousness  is  no  longer  occupied  with  the  abnormal 
disturbed  general  feeling,  OMing  to  subsidence  of  the  sensory  neu- 
rosis, then  inhibition  and  depression  disappear. 

In  this,  hypochondria  differs  from  hypochondriac  melancholia, 
in  which  the  primary  painful  depression  and  the  inhil)itin]i  (witli 
possible  delusions  of  littleness  and  sin),  with  a  profoundly  disturbed 
state  of  general  feeling  (usually  based  upon  special  causal  or  accom- 
panying physical  disease),  occur  together,  and  the  latter  is  used  in  at- 
tempts to  explain  the  abnormal  depression  and  inhibition. 

Hypochondria  has  numerous  points  in  common  with  neuras- 
thenia, in  that  not  infrequently  the  latter  neurosis  is  the  somatic 
foundation  and  point  of  origin  of  hypochondriac  depression  and  de- 
lusions. Essentially,  however,  the  two  states  must  be  separated,  for 
not  always  is  the  hypochondriac  a  neurasthenic  nor  the  neurasthenic 
a  h}'poehondriae,  even  though  it  must  be  admitted  that  the  neuras- 
thenic is  almost  always  nosophobic. 

The  IlYrociioxDEiAC  XEunorsTCHOsis. 

The  most  important  elementary  manifestations  on  the  psj'chic  side  of  the 
disea.se-pieture  of  hypochondria  are:  A  facilitated  power  of  apperception  of 
the  psychic  organ,  as  a  result  of  which  the  exciting  processes  (often  causal)  in 
the  nerves  of  other  organs,  usually  with  abnormal  changes  in  the  organs,  be- 
come clearly  conscious.  At  the  same  time  they  become  intensely  colored,  by 
lively  feelings  of  displeasure,  which  may  attain  the  degree  of  afl'ects  (psychic 
hyperesthesia).  Consciousness  is  not  only  constantly  disquieted  by  these 
painful  feelings  and  entirely  occupied  with  them,  even  to  the  degree  of  inhibi- 
tion of  all  other  feelings  and  ideas,  but  also  forced  to  interpretations  of  them, 
which,  according  to  the  individuality,  the  state  of  consciousness  of  the  patient, 
as  well  as  the  kind  of  the  causal  physical  disease,  may  extend  from  ideas  of 
severe  disease  to  the  most  absurd  interpretations  of  sensations  that  are 
actually  experienced. 

In  this  constant  readiness  for  allegoric  and  often  absurd  distortion  of 
sensations,  explicable  as  due  to  inhibitory  processes  which  affect  all  thought, 
and  in  consequence  critical  power  and  reflection,  as  well  as  in  the  largely 
original  illogical  character  of  the  patient,  the  hypochondriac  resembles  the 
paranoiac.  With  Merklin,  we  are  not  unjustified  in  calling  hypochondria,  on 
account  of  these  facts,  a  mild  form  of  paranoia  that  is  compatible  with  an 
external  show  of  reason.  The  transitions  from  hypochondria  to  certain  hypo- 
chondriac states  of  paranoia  are  easy.  At  the  height  of  hypochondria  repro- 
duced concepts  are  also  colored  with  lively  feelings,  which  may  attain  the 
degree  of  affects,  and  a  state  of  sensorial  hyperesthesia  develops  in  which  ideas 
call  up  corresponding  sensations  (hallucination  of  general  sensibilitj')-  The 
effect  of  inhibitory  processes  shoAvn  in  the  continued  and  increasing  organic 
sensory  influence  upon  con.sciousness  is  seen  in  all  directions  of  mental  activity. 
With  reference  to  intelligence  in  general,  it  is  remarkable  that  the  allegories 
and  interpretations  of  sensations  grow  more  and  uKjre  absurd.     In  thought 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        507 

and  feeling,  as  a  result  of  inliibition  of  pleasurable  sensations,  desperate  psycliic 
anesthesia  arises,  which  also  afl'ects  the  sense-perceptions ;  owing  to  inhibition 
of  ethic  ideas  and  feelings,  in  association  with  the  painful  state  of  tlie  ego, 
egotism  develops;  owing  to  the  absence  of  ethic  feeling  and  ideas  causing  lack 
of  sense  of  propriety,  all  possible  physical  functions  are  carried  out  or  dis- 
cussed before  others.  Inliibition  of  the  general  activities  is  shown  in  despair- 
ing apathy  and  lack  of  energy. 

The  hypochondriac  has  but  one  object  in  life,  one  thought:  to  find  relief 
for  his  fancied  frightful  malady.  With  this  in  view  he  consults  one  physician 
after  another,  swallows  prescription  after  prescription,  subjects  himself  to  all 
possible  forms  of  treatment,  and  as  a  result  is  more  reduced,  is  made  sick  by 
drugs,  and  finally  resorts  to  homeopathy,  quackery,  and  mysterious  cures — 
but  all  in  vain.  His  troubles  grow  worse  with  the  increasing  hyperesthesia 
that  spreads  to  all  sensory  areas;  his  abnormally  excited  imagination  con- 
jures up  for  him  the  most  frightful  pictures  of  disease  which  immediately 
make  their  impression  upon  the  physical  condition  by  calling  up  corresponding 
sensations.  At  the  height  of  his  malady  he  is  incapable  of  occupying  himself 
with  anything  other  than  the  processes  taking  place  in  his  diseased  body,  seeks 
in  his  excrement  for  tapeworms,  takes  the  papiilte  of  the  tongue  for  the  be- 
ginnings of  cancer,  finds  tubercle  in  his  sputum,  and  sees  evidence  of  stone  in 
the  sediment  of  his  urine.  Harmless  efflorescence  on  the  skin  is  a  proof  of 
syphilis;  palpitation  is  a  sign  of  threatening  cardiac  paralysis;  neurasthenic 
symptoms  point  to  tabes;  pressure  in  the  head  and  headache  are  absolute 
proof  that  softening  of  the  brain  is  coming  on,  etc.  The  patient  is  in  constant 
emotional  excitement  and  imagines  the  sufi"erings  of  inevitable  frightful  death. 
At  times,  as  complications,  there  are  spontaneous  feelings  of  anxiety.  They 
may  become  intensified  to  raptus  and  lead  to  suicide. 

In  part  causing  and  in  part  accompanying  hypochondria,  there  are  many 
nervous  symptoms, — hyperesthesias,  neuralgias,  paralgias,  paresthesias,  and 
occasionally  also  anesthesias  of  the  spinal,  cerebral,  and  sympathetic  nerves, 
hyperesthesia  of  the  sense-organs,  and  episodically  even  hallucinations;  not 
infrequently,  also,  the  symptom-complex  of  cerebral  and  spinal  neurasthenia. 
Motor  disturbances  (reflex  spasm,  respiratory  spasm,  globus,  vasomotor  and 
secretory  disturbances)  are  not  infrequent. 

Hypochondria  is  a  very  frequent  malady,  especially  in  men.  Episodically 
and  in  a  mild  form  it  may  affect  any  person  whose  general  feeling  is  disturbed 
by  physical  disease;  but  such  cases  are  without  significance  in  comparison 
with  those  in  which  it  is  a  constitutional  neurosis,  having  its  origin  in  heredi- 
tary predisposition,  which,  when  it  begins  at  puberty,  or  even  in  childhood, 
continues  throughout  the  life  of  the  individual,  in  that  it  is  awakened  by  all 
possible  organic  or  psychic  causes  (biologic  phases  of  life;  chronic  diseases  of 
tlie  alimentary  tract,  of  the  liver,  of  the  heart,  of  the  sexual  and  urinary 
organs,  often  quite  harmless  in  nature ;  neurasthenia,  ennui,  life  in  boarding- 
schools,  association  with  hypochondriacs,  reading  of  certain  popular  medical 
writings,  epidemics).  Like  all  neuroses,  hypochondria  presents  a  remitting, 
exacerbating  course,  often  referable  to  internal  and  external  influences. 

When  not  based  upon  hereditary  taint,  hypochondria  is  usually  tempo- 
rary, and  ends  in  recovery  after  a  few  weeks  or  months.  Constitutional  hypo- 
chondria presents  only  intermissions,  and  not  infrequently  ends  in  serious 
states  of  degenerative  mental  disease. 


508  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Cases  in  whicli  lij-pochondria  presents  itself  as  a  complication  in  the 
course  of  a  severe  brain  disease  (lidc  "Dementia  Paralytica")  are  not  to  be 
confounded  with  the  disease-picture  of  hypochondria  as  an  independent  neu- 
rosis. From  the  standpoint  of  treatment,  it  must  be  kept  in  mind  that  hypo- 
cliondria  is  always  dependent  upon  a  physical  disease,  which  must  be  found  and 
treated.  In  practice  this  is  mucli  sinned  against,  for  the  hypocliondriac  is 
taken  to  be  an  imaginary  invalid.  Strictly  speaking,  there  is  no  such  thing  as 
patients  imagining  disease,  but  only  patients  who  exaggerate  their  malady 
t>\ving  to  abnormal  sensations  (hyperesthesia)  which  are  not  in  accord  with 
objective  conditions,  with  the  consequent  egotism  and  exaggerated  invalidism. 
The  sensations  of  the  hjpocliondriac  are  not  imaginary.  Their  delusions  are 
no  more  devoid  of  a  somatic  foundation  than  are  those  of  so  many  other 
psychic  invalids,  but  the  interpretation  is  insane  and  often  absurd. 

The  treatment  of  the  hypochondriac  must  be  both  mental  and  physical. 
Mental  treatment  of  the  hyperesthetic  patient  must  be  principally  directed  to 
quiet,  distraction,  and  amusement. 

The  fundamental  condition  for  mental  treatment  is  that  the  patient  have 
faith  in  his  physician.  By  sympathy  and  consideration  of  the  patient's 
troubles,  and  careful  physical  examination,  we  seek  to  obtain  this.  Once 
acquired,  we  can  then  proceed  forcefully;  certainty  and  consequence  of  man- 
ner impress  the  patient,  ridicule  embitters  him;  like  the  paranoiac,  he  is  not 
amenable  to  logical  proof  of  his  errors. 

Psychic  distraction  by  well-ordered  activity  is  extremely  important. 
Many  men  fall  ill  in  this  way  by  changing  from  an  active  to  an  inactive  life. 
Ordered  activity  or  occupation,  however,  must  not  be  a  tax  upon  mind  and 
body,  nor  should  it  be  merely  mechanical,  purposeless,  and  tiresome.  Often 
short  pleasure  journej^s,  water-cures,  gymnastics,  writing,  etc.,  prove  useful. 
At  the  height  of  the  disease  owing  to  the  general  hyperesthesia,  rest,  or  even 
temporary  rest  in  bed,  is  necessary. 

I^rugs  find  their  psychic  indication  also.  Without  medicines  the  hypo- 
chondriac is  not  calmed.  If  there  be  no  somatic  indications  for  medication, 
then  placebos  should  be  given.  In  doing  this  the  patients  are  not  made  drug 
invalids. 

The  starting-point  of  somatic  treatment  lies  in  the  causal  or  accompany- 
ing physical  diseases  (sexual  troubles,  affections  of  the  alimentary  tract,  neu- 
rasthenia), the  treatment  of  which  is  to  be  carried  out  in  accordance  with  the 
indications;  and  it  never  should  be  routine,  but  adjusted  to  the  individual  con- 
stitution, the  circumstances  of  life,  and  the  mental  needs. 

There  is  a  great  obstacle  in  carrying  out  logical  treatment  in  the  mental 
condition  of  the  patient,  who  is  often  also  originally  mentally  abnormal. 
Weakening  cures,  prolonged  administration  of  salts,  and  cures  at  Carlsbad, 
which  have  a  profound  effect  upon  tissue-change,  as  a  rule  are  not  borne  by 
the  constitution  and  nervous  state  of  the  hypochondriac  (irritable  weakness, 
neurasthenia). 

In  general,  hydrotherapy,  electrotherapy,  climatic  cures,  sea-bathing, 
with  tonics  give  better  results.  Symptomatically,  quieting  drugs  may  be  neces- 
sary at  times,  especially  where  there  is  extreme  hyperesthesia  with  sleepless- 
ness and  attacks  of  fear.  Under  such  circumstances,  preparations  of  the 
bromides  and  hydrocyanic  acid  are  first  to  be  tried.  In  general  they  are 
better  borne  than  opiates. 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        509 

States  of  Mental  Weakness  Developed  from  Hypochondria. 

In  severe  and  generally  in  constitutional  hypochondria  states 
of  mental  weakness  often  constitute  the  terminal  phase  or  a  phase  of 
progressive  development. 

These  conditions  must  not  be  confounded  with  the  hypochon- 
driac form  of  dementia  paralytica.  They  do  not  go  on  to  complete 
dementia.  The  patient  sinks  into  a  despairing  state  of  apathy  and 
abulia,  which  is  but  occasionally  and  temporarily  interrupted  by 
feelings  of  fear  of  organic  origin.  The  affects  and  the  effort  of  the 
patient  to  find  help  diminish.  His  interest  in  the  world  and  in  things 
formerly  prized  disappears.  He  loses  the  last  trace  of  esthetic  regard 
.for  others,  grows  dirty  in  habits,  reckless  in  the  satisfaction  of  his 
bodily  needs,  occupies  himself  only  with  the  troubled  functions  of 
his  invalid  bod}^,  acquires  all  kinds  of  crazy  habits,  becomes  childish 
in  his  expression  of  any  emotion,  and  sillier  in  the  description  and 
interpretation  of  his  sufferings.  In  time  his  features  relax,  and  a 
marasmus  comes  on  in  which  evidently  the  brain  is  the  part  most 
affected  (senium  prascox). 

Case  58.- — Mental  weakness  due  to  hypochondria. 

J.,  physician,  aged  54,  married  for  manj^  years  to  an  hysteric,  insane  wife. 
Family  predisposed.  He  had  always  been  of  an  abnormal,  eccentric,  irritable, 
impossible  character,  inclined  to  hypochondria.  On  account  of  the  sickness  of 
his  wife  and  his  hard  life  in  his  calling  in  a  mountainous  region,  he  had  many 
cares  and  troubles.  His  invalid  wife  and  competition  interfered  with  his 
receipts.  In  1879  the  patient  acquired  a  chronic  gastro-intestinal  catarrh. 
He  became  sleepless,  hypochondriacally  depressed,  much  reduced  in  weight, 
and  had  attacks  of  fear,  in  one  of  which  he  made  an  attempt  at  suicide. 

On  August  8,  1879,  he  asked  to  be  admitted  to  the  psychiatric  clinic. 
Subcutaneous  fat  quite  absent,  gray-yellowish  color,  anemia,  chronic  gastro- 
intestinal catarrh,  signs  of  beginning  fatty  heart,  slow  pulse,  signs  of  begin- 
ning senility  (gerontoxon,  rigid  arteries)  were  the  physical  findings.  Mentally 
he  presented  the  picture  of  a  severe  hypochondria,  and  complained  that  his 
general  feeling  and  mental  feeling  were  absolutely  paralyzed.  He  felt  that  he 
was  without  feeling  and  emotion,  and  complained,  weeping  like  a  child,  that  he 
could  see  no  salvation  ahead  of  him.  With  this,  a  feeling  as  if  his  head  were 
as  large  as  a  pumpkin.  Numerous  paralgias  (feelings  as  if  worms  and  other 
vermin  Avere  gnawing  the  skin) ;  feelings  as  if  he  had  a  leaden  ball  in  his  abdo- 
men, as  if  he  were  about  to  be  confined,  as  if  the  intestines  were  wounded  or 
pinched  in  a  vise,  burning  in  the  rectum  going  up  to  the  brain.  After  eating, 
and  also  at  night,  the  patient  felt  fearful  distress  in  the  precordial  region.  He 
thought  he  was  about  to  die,  and  asked  to  have  a  telegram  sent  to  his  rela- 
tives. In  this  crisis  the  patient  had  globus,  respiratory  cramp,  sweating  from 
fear,  and  complained  of  cramps  in  the  hands  and  feet.  Occasionally,  in  such 
apprehensive  attacks,  he  sees  the  angel  of  death,  who  wishes  to  carry  him  off. 


510  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

He  clings  in  despair  to  those  about  liiin,  rolls  about  on  the  floor,  crying  in 
despair  for  help. 

The  malady  presents  remissions  and  exacerbations;  the  latter  always 
occur  in  connection  vitli  intensification  of  the  intestinal  trouble  and  lack 
of  stool;  often,  too,  in  connection  ■with  errors  of  diet  to  which  occasional 
bulimia  leads,  as  well  as  in  connection  witli  smoking,  to  which  tlie  patient 
abandons  himself  against  orders. 

Everything  is  used  in  the  way  of  food  and  medicine  to  bring  about  a 
favorable  change  in  the  condition,  which  is  essentially  one  of  chronic  gastro- 
intestinal catarrh  associated  with  the  malady,  but  in  vain.  In  states  of 
anxious  excitement,  opiates,  laurel-water,  sodium  bromide,  and  baths  some- 
times have  an  ameliorating  influence.  Temporarily  the  mental  and  physical 
condition  improves  under  strict  milk  diet  and  cessation  of  smoking;  but  the 
patient  always  disobeys  the  dietetic  orders,  takes  the  food  of  others,  and  in- 
creases his  weakness  with  renewed  exacerbations. 

The  patient  gives  himself  up  entirely  to  his  sensations,  and  complains 
like  an  hysteric  woman  of  innumerable  pains.  There  is  no  longer  a  drop  of 
healthy  blood  in  him.  He  has  not  a  single  healthy  organ.  He  is  reduced  to 
skin  and  bones.  His  flesh  has  fällen  off.  He  cannot  stand  it  much  longer. 
The  heart  breaks  in  two,  and  his  thread  of  life  breaks.  He  feels  as  if  worms 
were  gnawing  his  brain,  and  he  feels  the  loss  of  mental  power.  At  times  he 
feels  his  body  devoid  of  blood,  the  circulation  stopped,  and  he  feels  the  anemia 
of  his  brain  and  the  marasmus.  His  head  moves  backward  and  forward,  and 
he  has  a  partial  eclampsia.  His  feelings  change  every  instant.  Anxiety,  fear, 
depression,  cardiac  oppression.  He  has  no  more  thoughts;  cannot  write  a  let- 
ter. His  nerves  are  irritated  and  have  an  inimical  efl'ect  upon  him.  He  has 
no  more  vital  force,  and  he  is  hastening  to  his  end.  He  prefers  death  to  this 
martyrdom;  but  at  the  same  time  he  fears  death  and  asks  that  he  be  an- 
esthetized in  his  hour  of  agony.  The  point  of  origin  and  nucleus  of  all  his  dis- 
orders of  sensation  are  abnormal  gastro-intestinal  sensations. 

The  patient  complains  of  such  hj-peresthesia  throughout  the  alimentary 
tract  that  he  is  constantly  conscious  of  the  process  of  formation  of  feces  and 
peristaltic  action.  He  imagines  that  his  brain  is  in  his  abdomen  and  his 
intestines  in  his  brain.  He  has  a  constant  feeling  as  though  the  intestines  were 
injured.  The  rectum  burns  like  fire.  From  there  a  painful  feeling  rises  to  the 
heart,  and  from  there  to  the  brain.  In  the  latter  he  has  a  feeling  as  if  a  hand 
were  griping  him,  a  spasm  of  the  hemisphere.  However,  it  must  be  an  idio- 
pathic malady,  the  patient  says  with  a  cavernous  voice.  When  evacuation  is 
retarded,  he  feels  Irightful  atony.  He  then  feels  the  gases  mount  to  his  heart, 
and  expects  his  heart  to  stop. 

In  the  course  of  the  year  1880  the  patient  is  more  and  more  given  up  to  his 
troubles,  and  becomes  diül  to  external  matters  and  indifferent  to  his  relatives. 
His  former  interest  in  business  questions  disappears,  and  he  asks  no  longer  for 
the  newspapers  and  books,  and  occupies  himself  only  with  heart-beat,  pulse, 
tongue,  evacuation,  urine,  and  sees  in  all  signs  of  his  approaching  death. 

Toward  the  end  of  1880,  with  signs  of  increasing  mental  weakness,  he 
becomes  weeping,  hopeless,  brooding,  and  childish;  silly  emotion;  there  is 
noticeable  physical  marasmus.  His  face  becomes  sad,  wrinkled,  old.  The  pa- 
tient gives  himself  iip  to  monotonoiis  complaints  of  general  atrophy,  diminu- 
tion of  specific  gravity,  atony,  and  sclerosis  in  the  abdomen.     The  suspicion  at 


MENTAL  DISEASE  FROM  CONSTITUTIONAL  NEUROSES.        51 1 

first  entertained,  that  the  condition  was  an  hypochondriac  picture  in  a  case  of 
dementia  paralytica,  is  not  confirmed;  only  a  lasting  dilatation  of  the  right 
pupil  was  observed  in  the  course  of  the  year  1880.  Wlien  I  saw  the  patient 
for  the  last  time,  toward  the  end  of  October,  he  presented  a  simple  state  of 
hypochondriac  mental  weakness,  which,  when  the  evacuations  were  retarded, 
was  enlivened  by  violent  feelings  of  anxiety  that  increased  at  times  to  the 
degree  of  despair. 

In  the  beginning  of  1881,  in  sucli  an  attack  of  despaii',  he  committed  sui- 
cide by  breaking  a  window-pane  of  so-called  indestructible  glass  and  inflicting 
deep  wounds  with  pieces  of  the  glass,  so  that  death  occurred  from  hemorrhage. 

A  further  possible  termination  of  hypochondria  is  that  of  hypo- 
chondriac paranoia. 

While  in  simple  hypochondria  the  anomalous  sensations  are  still 
logically  considered,  and  the  patient  still  thinks  of  his  troubles  as 
lying  within  the  possibilities  of  actual  disease-states,  in  its  further 
course  not  infrequently  it  happens  that,  with  the  loss  of  the  last 
vestiges  of  reason,  the  patient  arrives  at  absurd  physical  and  med- 
ically impossible  interpretations  of  his  sensations.  The  facility  with 
which,  under  such  circumstances,  sensations  are  transformed  into 
ideas  of  a  delusional  character,  as,  on  the  other  hand,  ideas  give  rise 
to  sensations,  favors  the  development  of  this  simple  form  of  hypo- 
chondriac paranoia.  Then  hallucinations  further  aid,  as  a  rule,  in 
the  formation  of  the.dellisions.  The  transitions  from  hypochondria 
of  a  character  more  or  less  reasoning  to  this  form  of  paranoia  are 
easy.  In  other  cases,  with  the  patient's  loss  of  critical  power,  hypo- 
chondriac paranoia  arises  out  of  the  circumstance  that  the  sensations 
are  projected  into  the  external  world  and  ascribed  to  hostile  influ- 
ences (persecutory  form).  In  these  cases,  also,  the  further  develop- 
ment takes  place  in  obedience  to  hallucinations,  as  in  the  ordinary 
form  of  paranoia. 


PART   FOURTH. 
Chronic   Intoxications, 


CHAPTER  I. 

Chronic  Alcoholism  and  its  Complications. 

"\Vf,  imhiilo  uudcr  the  name  clirouic  alcoholism  (drunkenness), 
ill  trod  need  b}'  Magnus  Huss,  all  lasting  psychic  and  physical  dis- 
turbances of  I'lnu'lion  \\hirh  are  caused  by  tlie  habitual  abuse  of 
alcohol. 

The  anatomic  substratum  of  the  psychic  s^Tiiptoms  of  the  disease-picture 
are  chronic  inflammatory  changes  in  the  meninges  and  atrophic  processes  in 
the  cerebral  cortex  due  to  the  chemic  effect  of  alcohol  and  its  products  of  de- 
composition upon  the  cerebral  tissues,  as  well  as  to  the  congestion  and  stasis 
in  the  vessels  and  the  stasis  in  the  lymph-channels  of  the  brain  and  its  mem- 
branes. 

As  results  or  comjilications  there  are:  anomalies  in  the  distribution  of 
the  blood  (hj'peremias  and  anemias),  hydrocephalus  externus  and  internus, 
hyperostosis  cranii,  and  pachymeningitis  interna;  in  other  organs  there  are 
arteriosclerosis,  hypertrophy  of  the  lieart,  faity  heart,  chronic  gastro-intes- 
tinal  catarrh,f degeneration  of  the  \We^  and  kidneys. 

The  organic  changes  in  the  brain  and  its  coverings  mentioned  occur  only 
after  a  long  time  and  not  in  every  case.  They  appear  as  terminal  manifesta- 
tions and  as  the  remains  of  original  nutritive  disturbances  of  the  cerebral 
cortex  (disturbed  nutrition  and  circulation  as  a  result  of  the  abuse  of  alcohol)  : 
and  it  seems  that  with  a  brain  having  resistive  power  (intact  vascular  walls) 
the  picture  of  drunkenness  may  for  a  long  time  remain  merely  that  of  a 
functional  disease.  This  explains  the  possibility  of  recovery  in  the  early 
stages. 

As  a  result  of  this,  the  toxic  psychoses,  and  especially  alcoholism,  form 
the  natural  transition  from  the  functional  to  the  organic  psychoses,  and  they 
here  find  their  logical  consideration,  with  the  exception  of  the  infrequent  forms 
of  intoxication  which  have  already  been  described  under  etiology  (page  193). 

1.  The  fundamental  character  of  the  psychic  disturbance  is: 
psychic  weakness  and  the  progressive  insufficiency  of  the  ethic  and 
intellectual  functions. 

(a)  As  a  rule,  the  first  symptoms  manifest  themselves  in  the 
ethic  sphere.  The  drunkard  has  manifest  lax  principles  in  regard  to 
honor,  morality,  position,  and  indifference  to  moral  questions,  to  the 
,(512) 


CHKONIC  INTOXICATIONS.  513 

ruin  of  his  family,  and  tlie  coniempt  in  whicli  he  is  hclrl  by  his 
fellow-citizens.  He  becomes  a  brutal  egotist  and  cynic  (drunken  de- 
generation of  moral  feeling  and  temperament;  inhumanitas  ebriosa — • 
Clarus). 

(l)  With  this  there  goes,  hand  in  hand,  an  increasing  emotional 
irritability,  a  true  tendency  to  violent  anger.  The  slightest  causes 
induce  dangerous  affects  or  outbursts  of  rage,  which,  owing  to  the 
advanced  weakness  in  the  ethic  sphere,  are  uncontrollable  and  pre- 
sent the  features  of  pathologic  affects  (ferocilas  ebriosa). 

(c)  At  times,  especially  in  the  morning,  there  are  states  of  pro- 
found mental  depression  and  bad  humor  that  may  reach  the  degree 
of  tceditmi  vilce,  and  which  temporarily  disappear  under  renewed 
indulgence  in  alcohol  (morositas  ebriosa). 

(d)  An  early  manifestation  in  the  psychic  domain  is  a  remark- 
able degree  of  weakness  of  the  will  toward  the  fulfillment  of  the 
duties  of  occupation,  and  especially  those  of  citizenship.  These  show 
themselves  most  clearly  in  the  impossibility  of  carrying  out  good  re- 
solves, of  giving  up  the  vice,  which  find  their  most  striking  illustra- 
tion in  those  rather  frequent  cases  of  alcoholics  that  ask  to  be  placed 
in  an  institution;  for  they  are  still  intelligent  enough  to  notice  the 
abyss  at  the  brink  of  which  they  find  themselves,  and  are  at  the  same 
time  conscious  of  the  weakness  of  will  and  moral  feeling  that  makes 
it  impossible  for  them  to  avoid  indulgence. 

(e)  With  these  symptoms  finally  there  is  a  progressive  diminu- 
tion of  intellectual  power  in  toto,  which  early  shows  itself  in  weak- 
ness of  memory,  difficulty  of  thought,  and  dullness  of  apperception, 
which  may  even  progress  to  complete  dementia. 

(f)  A  striking  symptom  in  the  majority  of  cases  is  the  delusion 
of  chronic  alcoholics  that  stand  in  sexual  relations,  of  being  sexually 
deceived,  whether  it  be  by  the  wife  (delusion  of  marital  infidelity) 
or  by  a  mistress  (delusion  of  jealousy). 

I  have  found  delusions  of  jealousy  in  about  SO  per  cent,  of  male  alcoholics 
having  sexual  relations.  It  arises  in  the  later  stages  of  alcoholism,  and  with 
few  exceptions  is  an  isolated  quasi-mononianiacal  delusion. 

Owing  to  this,  and  also  to  the  fact  that  it  arises  almost  exclusively  idea- 
tionally  (by  combination),  at  first  sight  it  does  not  create  the  impression  of  a 
delusion,  and  even  for  the  mental  examination  it  is  often  necessary  at  first 
to  investigate  the  question  of  the  reality  of  the  facts  in  order  to  ascertain 
whether  the  idea  be  a  delusion  or  based  upon  facts. 

When  this  jealousy  has  once  arisen,  it  is  extremely  fixed,  and  only  excep- 
tionally have  I  seen  it  disappear  with  the  recovery  from  alcoholism.  This 
explains  the  fact  that  it  is  observed  in  the  various  forms  of  mental  disturb- 
ance, acute  and  chronic,  which  develop  upon  the  foundation  of  alcoholism. 

33 


51-i  SPECIAL  PATHOLOGY  AND  THER.APY  OF  INSANITY. 

But  it  existed  before  the  outbreak  auJ  was  not  tlie  product  of  the  epi- 
sodic or  complicating  psychosis.  The  delusion  belongs  to  alcoholism  per  se; 
it  is  a  stigma  of  alcoholism  as  a  mental  symptom,  and  of  primordial  origin. 

This  does  not  prevent  its  being  furthered  occasionally  by  hallucinations 
and  illusions  of  corresponding  content.  These,  however,  are  subsidiary  and 
belong  to  episoiles  of  drunkenness,  aUccts,  or  delirium. 

The  question  with  reference  to  the  manner  of  origin  of  this  delusion  is  a 
difKcult  one  to  answer,  ^^'ithout  doubt  it  is  related  to  alterations  of  feelings 
and  functions  in  the  genital  sphere.  Only  careful  mental  and  pliysical  explora- 
tion of  the  patient,  with  a  history  of  the  sexual  relations  with  the  wife,  can 
throw  light  upon  the  pathogenesis  of  the  delusion. 

It  is  to  be  remembered  that  the  abuse  of  alcohol  in  the  beginning,  and 
for  a  long  time  thereafter,  has  a  temporary'  aphrodisiac  efTect,  and  intensifies 
the  excitability  and  excitement  of  genital  centers,  until,  in  obedience  to 
physiologic  law,  the  terminal  opposite  phase  of  exhaustion  and  loss  of  the 
function  comes  on.  In  a  number  of  cases  in  which  I  was  able  to  investigate 
the  circumstances,  there  Avas  always  a  condition  of  hypcraesthesia  sexualis. 
The  abnormal  impulse  was  intensified  in  the  first  period  of  alcoholism,  but  in 
the  performance  of  coitus  the  man  failed  to  find  satisfaction,  because  the  feel- 
ing of  lustful  pleasure  was  wanting. 

On  the  part  of  the  wife,  who  accommodates  herself  to  the  act  only  with 
reluctance,  there  is  a  cause  of  absence  of  satisfaction  to  the  husband  in  her 
want  of  sensual  pleasure. 

The  causes  of  the  coldness  of  the  wife  are  advancing  age,  aversion  to  the 
rough,  brutal  husband,  often  drunk  at  the  time  of  intercourse,  who  lives  with 
the  wife  in  an  unhappy,  contentious  state.  Aversion  to  intercourse  results 
also  from  the  pathologically  tardy  ejaculation,  which  causes  pain,  through  the 
persistent  and  frequent  attempts.  In  the  later  stages  of  alcoholism  it  is 
fortiniate  if  the  man  becomes  absolutely  or  relatively  impotent. 

These  are  the  psycho-physical  elements  out  of  which  the  delusions  of 
jealousy  develop  as  soon  as,  in  the  course  of  alcoholism,  a  certain  degree  of  in- 
tellectual and  ethic  weakness  has  come  on. 

The  brutal,  irritable,  mentally  enfeebled  husband,  Avho  otherwise  lives  in 
a  state  of  quarrel  with  his  wife,  seeks  and  finds  the  cause  of  his  sexual  dissat- 
isfaction in  the  infidelity  of  the  wife.  The  delusion  becomes  fixed  and  elab- 
orated purely  by  means  of  false  combinations.  The  children  do  not  resemble 
the  father;  therefore  they  are  not  his.  In  the  household  there  is  privation 
because  the  husband  spends  everything  in  drink ;  therefore  the  unfaithful  wife 
gives  money  and  food  to  her  lovers.  The  wife  takes  care  of  her  personal  ap- 
pearance for  innocent  reasons;  therefore  it  is  because  she  wishes  to  please 
others.  These  are  the  essential  elements  of  the  delusion.  Only  in  affect,  intox- 
ication, or  occasional  delirium  are  illusional  or  hallucinatory  perceptions  experi- 
enced (loving  glances,  obscene  language  on  the  part  of  the  wife,  sight  of  her 
in  flaf/ranti,  surprising  in  rendezvous,  mistaking  of  persons,  etc.). 

The  mental  and  ethic  enfeeblement  of  the  drunkard  explains  the  fact 
tliat  he  often  takes  the  father,  the  son,  the  brother,  etc.,  to  be  the  guilty 
person. 

2.  Next  to  the  psychic  phenomena  come  sensorial  disturbances 
as  early  symptoms  of  chronic  alcoholism.    In  large  part  they  depend 


CHRONIC  INTOXICATIONS.  515 

lipon  circulatory  disturbances  in  the  brain  (chronic  Iiypcrcniias),  and 
express  themselves  in  headache,  dizziness,  heaviness,  mental  indis- 
position, confusion,  mental  embarrassment,  and  restless  sleep  with 
agitated  and  anxious  dreams. 

3.  The  sense-organs  present  important  disturbances.  They  are, 
in  part,  referable  to  circulatory  disturbances,  and  consist  at  first  of 
hyperesthesias  and  elementary  subjective  sense-impressions  going  to 
the  degree  of  hallucination;  later,  of  anesthesias. 

Sight  is  most  frequently  implicated;  then  hearing.  The  phantasms  con- 
sist of  mouches  volantes,  sparks  and  flames,  the  subjective  sounds  of  roaring, 
ringing,  and  hissing.  These  not  infrequently  are  accompanied  by  evident 
acoustic  hyperesthesia.  From  the  phantasms  and  tinnitus  very  frequently 
illusions  develop  that  are  erroneously  called  hallucinations.  Actual  hallucina- 
tions also  occur,  at  first  immediately  before  going  to  sleep,  later  episodically 
throughout  the  course  of  the  disease  after  weakening  influences  (want  of 
alcohol,  disturbed  sleep,  insufficient  food,  etc.). 

They  depend,  in  a  large  part,  upon  anemia  of  the  central  sense-organs, 
are  almost  exclusively  visual,  rarely  auditory,  and  have,  for  the  most  part,  a 
frightful  content  that  induces  fear  (horrible  masks,  specters,  animals,  etc.).^ 

In  the  course  of  the  malady,  as  Galezowski  and  others  show,  there  may 
be  amblyopia.  It  comes  on  suddenly,  and  the  acuteness  of  vision  diminishes 
decidedly.     The  patient  becomes  myopic  and  sees  better  at  night. 

Now  and  then,  as  a  result  of  spasmodic  affection  of  the  muscles  of  ac- 
commodation, there  is  diplopia  and  polyopia,  and  not  infrequently  temporary 
color-blindness  is  observed.  The  pupils  are  dilated  and  frequently  unequal. 
The  ophthalmoscope  shows  nothing  more  than  extreme  edema  of  the  retina 
and  narrowly  contracted  arteries. 

The  visual  disturbance  may  disappear  in  a  few  months,  if  the  abuse  of 
alcohol  is  stopped.  This  rarely  happens,  and  therefore  the  result  is  atrophy 
of  the  optic  nerves,  with  amavirosis. 

4.  Very  early  in  alcoholics  the  integrity  of  the  motor  functions 
suffers. 

The  most  important,  earliest  and  most  frequent  lasting  disturbance  is 
tremor  of  the  voluntary  muscles. 

It  is  most  marked  in  the  tongue,  lips,  face,  and  hands.  However,  the 
tremor  may  temporarily  increase  to  general  tremor.     Nystagmus  also  is  not 


^  These  phantasms  are,  for  the  most  part,  multiple  (fantastic  animals, 
murderer  with  drawn  dagger,  etc.).  During  a  long  time  one  of  my  patients 
had  at  night  before  going  to  sleep  visions  of  two  men  dressed  as  policemen 
armed  with  bayonets.  They  asked  him  who  he  was  and  demanded  his  money. 
Later,  they  followed  him  in  the  street  in  the  daytime  step  by  step,  so  that 
he  went  to  the  police  for  protection.  Hlusions  also  occur  here,  such  as  seeing 
those  around  coal-black,  in  distorted  form,  or  as  the  devil  or  an  animal. 


516  SPECIAL  TATIIOLOGY  AND  TIlERArY  OF  INSAKITY. 

infroqupntly  seen.  Diagnostic  of  this  alcoholic  tremor,  associated  with  its 
form  and  the  manner  of  its  distribution,  is  the  circumstance  that  in  the  sober 
state  it  is  most  intense  and  diminishes  with  indulgence  in  alcohol.  Not  in- 
frequently, even  in  the  beginning  of  the  disease,  as  a  result  of  increased  reflex 
excitability  of  the  spinal  cord,  there  is  general  tAvitching  and  local  tonic 
cramps  in  the  calves.  They  occur  especially  at  the  time  of  falling  asleep,  and 
with  the  phantasms  are  the  principal  cause  of  the  difficulty  these  patients  ex- 
perience in  getting  to  sleep. 

In  the  advancexl  stages  of  chronic  alcoholism  there  are  signs  of  paralysis 
in  the  facial  domain,  as  well  as  in  the  extremities.  The  hands  become  weak, 
the  knees  bend,  the  gait  becomes  shuffling.  The  cause  of  tliose  motor  disturb- 
ances is  not  yet  known,  but  in  a  certain  numlier  of  cases  it  lies  in  disease  of 
the  peripheral  nerves  (polyneuritis). 

5.  Sensory  disturbances  are  very  frequent  in  advanced  chronic 
alcoholism. 

In  the  beginning  these  consist  of  hyperesthesias  and  neuralgias.  The 
hj'peresthesias  may  be  cutaneous  or  muscular.  Indeed,  Magnus  IIuss  describes 
a  peculiar  hyperesthetic  form  of  chronic  alcoholism.  As  a  rule,  the  hyper- 
esthesias are  not  general,  but  limited  to  the  extremities.  They  probably 
cause,  owing  to  the  increased  excitability  of  the  reflex  apparatus  of  the  spinal 
cord,  th^  spasmcKÜc  contractions  resembling  lightning-like  electric  discharges, 
and  the  tonic  cramps  of  the  muscles  of  the  calf. 

In  the  final  stages  of  chronic  alcoholism,  analgesias  and  anesthesias  are 
observed.  Thej'  are  usually  limited  to  the  forearm  or  merely  the  fingers, 
or  to  the  lower  extremities  as  high  as  the  knee;  but  they  may  also  afTect  the 
trunk.  Magnan  has  described  a  hemianesthesia  of  the  drunkard  as  an  espe- 
cially severe  form  of  anesthesia.  Sometimes  slowness  of  apperception  has  been 
observed  with  intact  sensibility. 

These  numerous  abnormal  sensations  are  not  infrequently  intei'preted  in 
an  allegoric  way  by  the  clouded  consciousness,  and  thus  become  the  basis  of 
delusional  ideas.  Thus  the  neuralgic,  lightning-like  pains  lead  to  the  delusion 
of  being  tortured  with  electricity;  the  paralgic  and  hyperesthetic  sensations 
lead  to  the  idea  that  snakes  and  insects  are  crawling  on  the  skin,  and  cause 
such  patients  constanth'  to  wipe  off  the  skin  and  shake  their  clothing. 

6.  In  addition  to  the  disturbances  of  the  circulation  due  to  arterioscle- 
rosis, fatty  heart,  etc.,  general  disturbances  of  the  circulation  appear  early  in 
alcoholics.  There  is  vascular  paralysis,  which  shows  itself  especially  in  dilata- 
tion of  the  vessels  and  slowness  of  the  circulation  in  the  face,  and  in  stasis  in 
the  IjTiiph-channels,  causing  trophic  disturbances  of  the  skin  (acne  rosacea). 
With  thi3  there  is  a  slow  and  usually  infrequent  pulse.  The  weakened  brain, 
with  paretic  vessels  and  incapable  of  resistance  to  congestion,  is  less  and  less 
able  to  bear  alcohol,  and  relatively  slight  indulgence  in  alcohol  immediately 
leads  to  fluxionary  hyperemias,  with  symptoms  of  pressure  and  irritation  (vide 
"Pathologic  States  of  Drunkenness";    roDip.  page  214). 

7.  An  early  phenomenon  in  drunkards  is  diminution  of  libido  sexualis 
and  of  sexual  power,  cA'en  to  impotence. 

8.  The  profound  disturbances  which  the  vegetative  organs  undergo  as  a 
result  of  the  continued  abuse  of  alcohol,  find  theh"  expression  in  premature 


CHRONIC  INTOXICATIONS.  517 

senility,  especially  in  trophic  and  circulatory  disturbances,  which  induce 
atheroma  of  the  arteries,  paralysis  of  the  vessels,  fatty  heart,  chronic  gastro- 
intestinal catarrh,  and  degeneration  of  the  liver  and  kidneys.  The  withered, 
discolored,  pale  skin;  the  cutaneous  anemia  with  capillary  dilatation  and 
venous  stasis;  the  tired  eyes  with  dilated  pupils  and  expressionless  glance; 
the  demented  mien  with  unstable  facial  innervation,  that  may  be  paresis  or 
paralysis;  tlie  relaxed  vacillating  attitude,— betray  the  psychosomalic  degen- 
eration of  the  alcoholic. 

The  course  of  chronic  alcoholism  is  progressive  to  the  most  ex- 
treme degrees  of  psychic  and  physical  decadence :  stupidity,  paresis, 
and  physical  decay. 

Earely  does  a  drunkard  reach  this  final  stage,  for  the  accom- 
panying diseases  of  the  vegetative  organs,  especially  cirrhosis  of  the 
liver,  dropsy,  uremia,  apoplectic  or  epileptic  attacks,  acute  inflam- 
matory aft'ections  (especially  of  the  lungs),  delirium  tremens,  etc., 
bring  the  patient's  life  to  an  earlier  termination. 

Any  moderately  severe  disease  in  a  drunkard,  even  a  simple 
bronchitis,  may  become  grave  and  take  on  from  the  beginning  an 
adynamic  character. 

For  the  most  part,  the  prognosis  of  chronic  alcoholism  is  un- 
favorable, for  it  is  only  in  rare  instances  that  a  patient  so  afflicted 
can  be  saved  from  the  abyss  into  vi^hich  he  is  slipping,  and  he  is  sel- 
dom-able, in  spite  of  the  best  resolutions,  to  abandon  his  vice  of  his 
own  will. 

The  treatment  must  be  directed  principally  to  the  cause.  In 
private  care  it  is  impossible  to  stop  the  use  of  alcohol.  This  can 
only  be  done  in  hospitals,  and  best  in  asylums.  In  certain  coun- 
tries that  are  especially  afflicted  with  the  curse  of  drunkenness  spe- 
cial asylums  for  the  treatment  of  inebriates  have  been  built.  They 
are  of  great  benefit  to  individuals  as  well  as  to  society,  lessen  the 
number  of  accidents  and  crimes,  even  restore  some  almost  hopeless 
cases,  and  have  the  important  advantage  that  they  prevent  the 
transmission  to  descendants  of  infirmities  due  to  alcohol.  The  es- 
tablishment of  such  asylums  in  civilized  countries  cannot  be  too 
warmly  urged.  Forced  confinement  of  such  drunkards  is  justified  on 
the  clinical  basis  of  the  disease,  and  on  consideration  of  the  benefit 
such  individuals  deprived  of  free  will,  irresponsible,  and  decidedly 
the  subjects  of  brain  disease,  derive  from  it.  Since,  however,  at  the 
present  time  such  asylums  are  wanting,  the  worst  cases  of  chronic 
alcoholism  are  sent  to  the  asylums  for  the  insane,  where  they  do  not 
strictly  belong,  save  perhaps  while  they  are  in  states  of  intercurrent 
agitation,  and  out  of  which,  after  the  complications  have  disappeared, 
they  pass,  to  relapse  in  a  short  time. 


518  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANMTY. 

Only  a  prolonged  residence  in  an  asylum,  where  everytliing  of 
an  alcoholic  nature  is  prohihited  and  the  patient  is  systematically 
weaned  from  this  nerve-stimulant,  can  afford  help. 

We  mention  only  in  passing  llu'  injui-ious  or  nsoloss  brandy 
treatment,  witli  tincture  of  quinine,  sulphuric  acid,  or  tartar  emetic, 
so  often  prescribed  without  success  in  private  practice. 

For  the  general  practitioner  it  is  important  to  understand  the 
fact  that  weakening  measures  in  drinkci's  easily  bring  on  complica- 
tions, especially  delirium  tremens,  and  that  acute  diseases  take  on 
an  asthenic,  pernicious  character. 

Case  59. — Chronic  alcoliolisni  willi  rcmark;il)le  dcgcnei-atinn  of 
morals  and  character  (inliuiiianitas  and  ferocitas  ebriosa).  Brutality 
to  the  wife  in  a  condition  of  drunkenness  and  excitement. 

H.,  aged  50,  land-owner;  parents  were  given  to  drink.  Of  thirteen  chil- 
dren in  the  familj'-,  only  two  are  living.  They  are  choleric-,  brutal  men,  given 
to  drink. 

The  patient  was  a  great  drinker  from  his  youth.  In  1871,  when  he  mar- 
ried a  wife  who  had  not  the  best  reputation,  he  was  morally  and  intellectually 
defective.  Of  late  years  he  had  indulged  more  and  more  in  strong  spirits,  and 
his  mental  and  physical  strength  rapidly  diminished.  The  patient  became 
more  and  more  dulled  in  moral  feeling,  spoke  the  vilest  language,  called  his 
wife  vile  names.  He  treated  the  servants  shamefidly  and  even  maltreated 
them. 

He  neglected  his  business.  Spent  his  time  in  saloons,  was  almost  never 
sober,  and  even  at  night  on  awaking,  drank  quet-scii,  and  in  the  morning  lie 
could  not  stand  up  for  drunkenness.  His  states  of  intoxication  became  more 
and  more  patliologic.  He  cried,  scolded,  wept  indiscriminately,  spoke  without 
sense,  broke  what  was  in  his  hands,  threatened  those  around  him  with  knife 
and  revolver;    so  that  everj'body  feared  him. 

For  some  years,  on  falling  asleep  and  at  night  ^vhen  he  awoke,  he  had 
had  sensory  and  sensorial  disturbances.  The  bed  danced  with  him ;  he  saw 
dark  forms  passing  in  the  air;  saw  birds,  mice,  rats,  dogs,  and  cats  flying 
about  in  the  room.  With  this  he  had  roainng,  hissing,  and  humming  in  his 
ears,  heard  confused  cries,  and  only  with  dilficulty  recognized  that  this  was  all 
deception.  Sleep  was  bad.  When  he  awoke  he  was  usually  bathed  in 
l^erspiration. 

On  getting  Tip  lie  had  such  severe  vertigo  that  he  had  to  hold  on  to 
something;  headache,  vomiting  of  thick  mucus,  general  tremor  so  that  he 
could  not  put  a  spoon  to  his  mouth.  When  he  took  more  brandy  he  was  bet- 
ter and  the  tremor  disappeared. 

December  29,  1874,  the  patient  had  drunk  much  brandy  during  the  day 
and  was  angrily  excited  and  drunk.  In  the  afternoon  he  went  home  and  asked 
his  wife  to  give  him  sour  milk.  Because  she  did  not  have  it  at  hand  he  became 
violently  angry,  shot  twice  into  the  wall  with  his  revolver,  and  then  shot  his 
wife  in  the  abdomen  when  she  tried  to  calm  him.  When  his  wife  fell  he  came 
to  himself,  was  frightened,  and  wished  to  hang  himself. 


CHRONIC  INTOXICATIONS.  519 

Afterward  he  remeinbered  his  act  only  in  a  dreamy  way.  He  clearly  did 
not  wish  to  kill  his  wife;  only  frighten  her.  The  examination  in  prison  showed 
him  to  be  a  man  much  deteriorated  ethically  and  intellectually.  He  had  no 
anxiety  about  the  future  and  no  regret  for  his  deed.  His  expression  was 
morose  and  dull.  The  tongue  was  coated  and  trembling;  skin  faded  and  of  a 
dirty  yellow,  the  muscles  relaxed;  face  red,  capillaries  dilated;  the  eyes 
circled;  the  left  facial  domain  less  innervated  than  the  right;  slight  tremor 
in  the  handstand  lower  extremities.  No  disturbance  of  sensibility.  Pulse 
rare,  small,  slow.  Heart-soimds  dull.  Cardiac  dullness  somewhat  increased. 
The  liver  extended  beyond  tlie  line  of  the  ribs.  Appetite  poor.  Constipation. 
The  patient  complained  of  heaviness  of  the  head,  dizziness,  headache,  noises  in 
the  ears  (especially  in  the  morning),  chronic  bronchial  catarrh.  Sleep  bad, 
disturbed  often  by  fright  and  anxious  dreams.  Removal  of  alcohol  during 
imprisonment,  and  later  in  the  asylum,  had  a  beneficial  influence  upon  the 
seriously  damaged  bram,  but  the  patient  remained  ethically  and  intellectually 
weakened  and  incapable  of  self-guidance.  Attempts  to  give  him  more  liberty 
were  always  followed  by  new  excesses. 

On  the  clinical  basis  of  chronic  alcoholism  there  is  a  series  of 
intercurrent  complicating  affections  of  the  brain  which  in  part  have 
great  practical  importance.  These  are:  (1)  clelirinm  tremens;  (3) 
drunken  errors  of  the  senses ;  (3)  alcoholic  psychoses ;  (4)  alcoholic 
epilepsy. 

1.  Delieium  Tremens. 

One  of  the  most  important  and  frequent  intercurrent  affections 
in  chrouic  alcoholism  is  deliriimi  tremens.  As  the  name  indicates,  its 
fundamental  symptoms  are  deliri^,  and  tremor.  Further  symptoms 
that  are  never  wanting  are  sleeplessness  and  errors  of  the  senses. 
The  malady  occurs  only  in  those  given  to  habitual  over-indulgence 
in  alcohol,  who  present  more  or  less  clearly  the  symptoms  of  chronic 
alcoholism.  A  single  over-indulgence  in  alcohol,  no  matter  to  what 
excess,  never  induces  delirium  tremens. 

While  the  cerebral  disease  at  the  basis  of  chronic  alcoholism 
constitutes  the  predisposition  for  the  outbreak  of  delirium  tremens, 
there  are  a  number  of  exciting  causes  of  the  malady  that  must  be 
mentioned.  They  have  essentially  this  in  common,  that  they  have 
a  debilitating  effect  upon  the  brain  already  weakened  and  reduced 
in  resistive  power.  The  most  important  exciting  causes  are:  re- 
peated alcoholic  excesses  (ä  potu  nimio);  cessation  of  indulgence 
in  the  accustomed  stimulus  (ä  potu  intermisso)  ;  insufficient  nourish- 
ment due  to  lack  of  food  or  aggravation  of  the  chronic  gastric 
catarrh;  violent  emotions;  severe  diseases,  especially  pneumonia; 
profuse  suppuration;  loss  of  blood;  loss  of  sleep;  painful  diseases 
and  injuries,  especially  fractures. 


520  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  outbreak  of  delirium  tremens  is  never  sudden.  Very  fre- 
quently gastric  disturbances  are  present  as  prodromes,  or  there  is 
sleeplessness  with  frightful  hallucinations,  or  restless  sleep  with 
fearful  dreams  and  frequent  starting  from  sleep  in  fright;  morose- 
ness  and  irritability;  oppression  in  the  epigastrium,  that  may  attain 
violent  precoj-dial  anguish;  noises  in  the  ears;  hyperesthesia  of  the 
auditory  and  optic  nerves;  headache,  vertigo,  nervous  restlessness, 
and  slight  tremor  of  the  hands  and  tongue.  The  duration  of  this 
stage  of  incubation  may  reach  twelve  days. 

The  actual  paroxysm  consists  of  a  series  of  psychic,  motor,  and 
vegetative  functional  disturbances.  AVitli  continued  sleeplessness, 
psychic  excitement,  frequent  frights,  increasing  emotional  and  senso- 
rial excitement,  formal  disturbances  of  thouglit — which  the  patient 
describes  as  inability  to  keep  his  thoughts  together,  as  confusion  in 
his  head,  clouding  of  consciousness  and  delirium — come  on.  This  is 
always  only  superficial  and  dreamy;  and  in  a  measure  it  is  diagnostic 
of  such  conditions  that,  by  urging,  the  patient  can  be  momentarily 
induced  to  give  correct  answers,  though  he  immediately  relapses  into 
his  delirium. 

The  deliriimi  is  mainly  concerned  with  hallucinations.  The 
patients  frequently  think  that  they  are  in  saloons,  ask  for  drinks,  or 
that  they  are  about  their  occupation  and  busy  with  its  usual  details. 
The  hallucinations,  which  at  first  are  merely  those  of  sight  that 
occur  only  in  the  darkness,  or  during  the  day,  have,  for  the  most 
part,  a  frightful  content,  and  are  usually  visions  of  animals, — not  of 
a  single  animal,  but  of  herds  of  them, — horses,  dogs,  rats,  mice,  and 
the  like.  They  assume  aggressive  positions,  crowd  and  force  them- 
selves around  him,  storm  at  him,  snap  and  bite  at  him.  With  these 
there  are  ghost-like  forms,  hateful  masks,  but  always  in  crowds. 

Hyperesthetic  and  paralgic  sensations  awaken  in  the  patient 
illusory  perception  of  crabs,  snakes,  worms,  spiders,  etc.,  upon  the 
skin;  and  on  this  in  part  depends  the  constant  picking  of  the  bed- 
clothes and  wiping  of  the  skin  usually  observed  at  the  height  of  tlie 
disease.  Boils,  injuries,  etc.,  are  frequently  interpreted  in  the 
delirium  as  bites  of  animals,  attempts  at  murder,  etc.  All  visual 
hallucinations  occur  in  greater  number  in  the  darkness;  and  even 
during  convalescence  they  recur  as  soon  as  the  patient,  now  out  of 
his  delirium,  closes  his  eyes. 

In  the  course  of  the  delirium  auditory  hallucinations  ma}''  also 
occur,  consisting  of  confused  sounds,  noises,  roaring,  or  frightful 
voices,  not  infrequently  using  obscene  language ;  but  in  comparison 
with  the  predominating  visual  hallucinations  these  are  episodic. 


CHRONIC  INTOXICATIONS.  521 

It  is  essentially  the  hallucinations  that  keep  the  patient  in  con- 
stant agitation,  and  even  not  infrequently  cause  him  to  develop  an 
elementary  insanity  of  persecution.  Often,  too,  there  are  illusions: 
spots,  cracks,  and  wall-paper  designs  are  taken  for  animals,  and  the 
like.  Persons  that  surround  the  patient  are  also,  at  the  height  of 
the  disease,  mistaken  in  the  sense  of  the  predominating  deliria. 

Owing  to  the  frightful  hostile  content  of  the  errors  of  the  senses 
and  apperceptions,  acts  of  violence  toward  self  and  others  may  he 
committed. 

Quite  frequently  there  is  delusion  of  poisoning,  with  tempoi'ary 
refusal  of  food  in  such  delirious  patients,  due  to  the  presence  of  oral 
or  gastric  catarrh. 

The  motor  disturbances  consist  of  tremor,  especially  marked  in 
the  fingers  and  tongue,  frequent  also  in  the  muscles  of  the  face  and 
extremities;  and  these  may  even  he  intensified  to  general  tremor. 
The  gait  of  the  patient  is  tottering,  staggering,  uncertain.  Sensi- 
bility to  pain  is  frequently  absent.  States  of  analgesia  alternate  with 
states  of  hyperesthesia. 

Keflex  excitability  is  frequently  increased.  There  is  purposeless 
rolling  about  in  bed,  jerking  and  throwing  about  of  the  extremities, 
which  may  attain  the  degree  of  partial  or  general  clonic  spasm.  The 
pulse  may  go  to  100  or  more,  and  respiration  is  increased.  Perspira- 
tion is  usually  profuse.  The  urine  diminishes,  becomes  concentrated, 
of- high  specific  gravity,  and  not  infrequently  contains  a  considerable 
amount  of  albumin.  There  is  constipation.  Gastric  complications 
are  always  found.  At  the  height  of  the  disease  sleep  is  absolutely 
wanting. 

Delirium  tremens  is  in  itself  a  nonfebrile  disease,  though  not 
infrequently  here,  as  in  the  severe  neuroses  in  general,  sudden  and 
very  considerable  elevation  of  temperature  may  occur,  which,  when 
complicating  diseases  of  the  vegetative  organs  are  excluded,  can  only 
be  referred  to  anomalies  of  innervation  in  the  cerebral  centers  that 
regulate  temperature. 

Magnan  has  called  such  conditions  febrile  delirium  tremens, 
and  contrasted  them  with  afebrile  delirium  tremens,  as  constituting 
a  very  severe  form.  These  may  occur  primarily.  Under  such  circimi- 
stances  partial  clonic  and  general  epileptic  spasms  are  frequent.  The 
temperature  rises  rapidly  as  high  as  43°  C.  Death  is  almost  always 
the  termination  of  this  febrile  delirium,  which  I,  in  common  with 
Schule,  would  regard  clinically,  not  as  delirium  tremens,  but  acute 
delirium. 


522  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Very  frequcntl}'  the  delirium  lakes  on  an  adynamic  character. 
The  pulse  becomes  soft  and  small,  the  heart-sounds  dull,  and  even 
the  first  sound  may  disappear.  The  patient  collapses,  sweats  pro- 
fusely; the  delirium  is  low,  seldom  furious,  with  jerking  of  the 
tendons  and  carphology.  The  tongue  becomes  dry  and  foully  coated, 
and  consciousness  is  absent,  even  to  the  degree  of  sopor. 

Delirium  tremens  lasts,  on  an  average,  from  three  to  eight  days, 
though  relapses  are  frequent,  and  may  cause  the  malady  to  he  pro- 
longed for  several  weeks.  The  general  course  is  one  of  remissions  and 
exacerbations. 

Delirium  tremens  is  a  grave  malady,  since  about  15  per  cent, 
of  the  cases  end  in  death.  The  danger  lies  in  the  possibility  of  ex- 
haustion, the  occurrence  of  cerebral  complications  (edema,  acute 
delirium),  and  vegetative  diseases,  especially  hypostatic  pneumonias. 

The  terminations  of  delirium  tremens  are  death  by  exhaustion 
or  complications,  of  which  cerebral  edema  with  convulsions  is  espe- 
cially to  be  feared;  and  a  chronic  condition  (delirium  of  inanition), 
chronic  insanity,  or  recovery.  The  latter  may  in  mild  cases  occur 
quasi-critically  after  profound  sleep.  As  a  rule,  recovery  is  gradual, 
with  progressive  disappearance  of  jactitation  and  delirium,  and  pauses 
of  several  hours  of  sleep.  The  patient  passes  through  a  stage  of  phys- 
ical and  mental  prostration  (clouding  of  consciousness  possibly  to  the 
extent  of  stupor,  weakness  of  apperception),  in  which  the  deliria  are 
not  completely  corrected,  and  in  which  now  and  then  hallucinations 
may  recur.  These  in  time  are  recognized  as  such,  and  are  no  longer 
a  subject  of  anxiety.  The  psychoses  that  develop  out  of  delirium 
tremens  are  hallucinatory  insanity,  protracted  states  of  stupor,  mel- 
ancholias, and  manias.  They  do  not  differ  from  other  psychoses  due 
to  weakening  intiuences,  except  for  the  traces  of  chronic  alcoholism 
and  the  continuation  of  the  hallucinations  of  the  period  of  delirium 
tremens.  In  fatal  cases  of  delirium  tremens,  besides  the  changes  due 
to  chronic  alcoholism  (cloudiness  and  Ipnph-stasis  in  the  pia,  etc.) 
there  are  venous  hy^Dcremia  and  edema  of  the  pia  and  brain. 

The  treatment  of  delirium  tremens  must  take  into  considera- 
tion, first,  the  causal  indications,  and  then  the  S3anptomatic  indica- 
tions. 

With  relation  to  etiology,  prophylaxis  is  of  the  greatest  impor- 
tance. Physicians  practicing  in  public  hospitals  and  prisons  have 
abundant  opportunity  to  employ  it.  If  the  patient  be  a  drinker,  then 
he  should  not  be  entirely  deprived  of  his  habitual  nerve-stimulant; 
or  at  least  the  moment  a  grave  disease  is  present  it  should  be  pre- 
Bcribed;  otherwise  one  of  the  exciting  causes  of  the  delirium  becomes 


CHRONIC  INTOXICATIONS.  523 

active.  At  the  same  time,  care  must  be  exorcised  that  severe  or 
painful  disease  or  injury  in  a  drinker  be  not  treated  by  weakening 
means  (bleeding,  drastics,  etc.);  on  the  contrary,  strengthening  die- 
tetic and  medicinal  treatment  must  be  used. 

Since,  under  such  circumstances,  every  drinker  is  in  danger  of 
delirium  tremens,  any  possible  symptoms  of  incubation  shoidd  be 
carefully  looked  for,  especially  sleeplessness,  and  the  latter  should 
immediately  be  treated  with  hypnotics  (opium,  with  or  without 
spirits;  chloral  hydrate,  with  or  witlioiit  morphine;  paraldehyde, 
, amyl  hydrate,  sulphonal).  The  indications  for  treatment  of  the 
developed  disease  are  to  avoid  all  weakening  measures  and  to  induce 
sleep  as  quickly  as  possible. 

The  first  rule  is  justified  by  the  decidedly  asthenic  character  of 
the  inanition  delirium,  as  well  as  by  the  sad  result  of  former  weaken- 
ing treatment.  The  second  recommendation'  depends  upon  the  fact 
that  experience  has  taught  that  the  delirium  ceases  as  soon  as  the 
j)atient  obtains  a  deep  and  sufficiently  long  restoring  sleep. 

In  the  choice  of  hypnotics  there  must  be  fulfillment  of  individ- 
ual indications,  and  consideration  of  the  general  state  of  the  patient. 
Any  possible  complications  (fever,  inflammatory  diseases),  especially 
the  state  of  the  heart  (fatty  degeneration,  cardiac  weakness),  must  be 
taken,  into  consideration. 

Three  groups  of  cases  may  be  distinguished : — • 

1.  Cases  in  which  the  disease  occurs  for  the  first  time  in  strong  young 
persons,  without  fatty  heart,  without  arteriosclerosis,  especially  without  signs 
of  advanced  chronic  alcoholism,  without  complications,  and  without  fever. 
Here,  with  medicinal  doses  of  wine,  chloral  hydrate,  with  or  without  opium, 
suffices.  Smaller  doses  (chloral,  1  to  1.5  grams;  morphine,  0.01  gram),  but 
frequently  repeated,  every  three  or  four  hours,  have,  according  to  my  experi- 
ence, the  preference  over  larger  doses  given  less  frequently.  If  the  case  is  one 
suitable  for  chloral,  then  its  hypnotic  effect,  as  a  rule,  comes  on  after  the  sec- 
ond or  third  dose.  Sometimes  its  effect  is  not  obtained,  and  it  may  even  in- 
crease the  excitement.  Under  such  circumstances  its  continued  use  and  larger 
doses  are  of  no  use  and  seem  even  dangerous. 

A  drug  almost  as  useful  as  chloral,  though  not  so  prompt  in  its  effect, 
though  less  dangerous  and  less  frequently  without  effect,  and  which  at  the 
same  time  can  be  more  generally  employed,  is  opium.  In  the  hospital  we 
prefer  to  use  it  subcutaneously  rather  than  internallj';  for,  used  in  this  way 
the  dosage  is  exact,  and  absorption  by  the  stomach,  owing  to  the  usual  severe 
gastric  catarrh  in  chronic  alcoholism,  seems  problematic  and  imperfect,  as  is 
proved  by  the  enormous  doses  of  opium  Avhich  such  patients  bear  and  require 
when  it  is  thus  given. 

Used  subcutaneously,  the  irritative  effect  on  the  gastric  catarrh  of  opium 
used  internally  is  avoided,  which  is  an  important  advantage  to  the  patient, 
whose  rapid  convalescence  and  avoidance  of  relapses  depends  especially  upon 


524  SPECIAL  PATHOLOGY  AND  THEEAPY  OF  INSANITY. 

tlie  Cüiulition  of  digestion  and  assimilation.  The  initial  dose  should  be  0.03 
gram  of  the  exiracti  uini  aqiwsiT,  and  repeated  every  three  or  four  hours  until 
sleep  is  induced.  If  subcutaneous  treatment  is  impossible  (country  practice), 
the  remedy  should  be  given  by  enema  or  in  suppositories. 

It  is  of  great  importance  not  to  stop  the  opium  immediately  -when  its 
hypnotic  ellect  is  apparent;  otherwise  relapses  easily  occur.  The  danger  of 
these  is  decidedly  lessened  if  the  opium  treatment  be  continued  several  days,  in 
STualler  doses  of  0.01  to  0.G2  gram,  after  the  critical  sleep,  especially  if  given 
in  the  evening  after  convalescence  has  begun. 

2.  A  second  gi-oup  of  cases  is  characterized  by  the  presence  of  physical 
complications  (pneumonia,  grave  injuries),  or,  where  these  are  wanting,  by 
fever,  which  under  such  circumstances  must  be  regarded  as  a  neurotic  symp- 
tom, and  which,  as  jSlagnan  emphasized,  renders  the  prognosis  most  decidedly 
unfavorable;  or  we  have  to  deal  with  cases  in  which  there  are  evidences  of 
advanced. alcoholic  marasmus,  with  fatty  degeneration  of  the  organs,  especially 
of  the  heart,  and  signs  of  cardiac, weakness  (dull  heart-sounds,  weak  heart- 
beat, rapid  pulse,  Avant  of  arterial  tone).  Under  such  circimistances,  chloral, 
being  a  decided  heart  poison,  which  may  induce  cardiac  paralysis  through  the 
medulla,  is  decidedly  contra-indicated.  In  such  cases  the  use  of  opium  is  indi- 
cated, and  not  dangerous,  if  the  possibility  of  cardiac  weakness  is  combated  by 
stimulants,  preferably  wine  or  spirits  in  generous  doses,  and,  in  case  of  neces- 
sity, by  acetic  ether  or  ammonia.  In  these  cases  the  hypnotic  treatment  may 
be  forced,  if  the  activity  of  the  heart  is  carefully  watched  and  the  stimulants 
increased  with  the  increase  of  the  opium.  Paraldehyde  up  to  12  grams,  and 
amyl  hydrate  up  to  6  grams,  as  the  dose  for  twenty-four  hours,  are  also 
indicated. 

3.  A  third  group  comprises  cases  in  which,  owing  to  neglect, — severe  com- 
plications, high  fever,  advanced  alcoholism,  repeated  relapses  of  the  delirium, — 
the  patient  is  in  a  marked  adynamic  state,  with  profound  disturbance  of 
consciousness,  heavily  coated  tongue,  collapsed  features,  muttering  delirium, 
carphology,  subsultus  tendinum,  cardiac  weakness,  and  a  weak  pulse,  beating 
120  or  more.  In  such  cases  scarcely  anything  is  to  be  expected  of  narcotics, 
and  their  application  is  even  dangerous.  Here  only  a  restorative  and  decidedly 
analeptic  treatment  can  save  the  patient's  life.  The  best  hypnotic  and  calma- 
tive means  is  strong  wine  in  generous  doses.  If  the  heart's  action  is  insuffi- 
cient, camphor  or  musk  may  be  given.  If  sopor  occurs,  then  cold  douches  are 
of  use.  If  the  danger  to  life  is  overcome,  then  treatment  with  opium  or 
paraldehyde,  as  under  Group  2,  may  be  begun  cautiously. 

With  the  attainment  of  restorative  sleep,  care  to  improve  as 
much  as  possible  the  nutrition  of  the  patient  is  the  principal  thing 
in  delirium  tremens.  The  condition  of  the  stomach  makes  this  very- 
difficult.  At  the  height  of  the  disease  a  milk  diet  is  the  most  ad- 
vantageous. The  best  is  milk  thinned  with  soda-water  or  a  natural 
acidulated  water.  If  by  jactitation  and  constant  rising  from  the  bed 
the  patient  is  in  danger  of  exhaustion,  then  restraint  (in  severe 
cases)  cannot  be  avoided.  Since  the  patients  are  dangerous  to  them- 
selves and  others,  isolation  in  a  well-warmed  room  and  careful  sur- 


CHRONIC  INTOXICATIONS.  525 

veillance  are  necessary.  Innumerable  accidents  make  this  absolutely 
imperative.  As  an  example,  I  will  mention  an  accident  which  occurred 
years  ago  in  the  Berlin  Charitc,  where  a  delirious  patient,  during 
the  momentary  absence  of  the  nurse,  broke  the  skull  of  a  ncigli bor- 
ing patient. 

Cases  of  delirium  tremens  do  not  belong  in  asylums.  All  large 
towns,  especially  in  countries  that  produce  wine,  should  have  cells 
for  delirious  patients.  When  convalescence  begins,  the  maintenance 
of  sufficient  sleep  and  the  restoration  of  a  good  state  of  general 
nutrition,  especially  treatment  of  the  gastric  catarrh,  are  the  most 
important  objects  of  therapy.  With  the  dietetic  treatment,  prepa- 
rations of  quinine,  preferably  a  decoction  of  quinine  with  muriatic 
acid,  are  useful;  also  subcutaneous  injections  of  strychnine,  0.001 
gram,  two  or  three  times  daily. 

Case  60. — Delirium  tremens.  Treatment  with  morphine  and 
chloral. 

S.,  aged  32,  laborer,  not  tainted,  previously  always  healthy,  a  drinker 
of  wine  and  beer  for  years.  Since  August  17th,  after  extreme  alcoholic  ex- 
cesses, he  had  felt  tired,  depressed,  without  appetite,  slept  badly,  had  frightful 
dreams,  and  woke  up  frequently.  Excessive  indulgence  in  brandy  on  August 
26th.  The  following  night  he  was  still  more  frightened  and  saw  his  home 
burn  and  the  flames  licking  about  his  bed.  He  was  as  if  paralyzed  with  fright. 
Then  the  devil  and  curious  enormous  insects  came  and  danced  about  him.  He 
also  felt  them  sting  and  bite  him.  The  room  vs^as  filled  with  a  legion  of 
thieves,  robbers,  and  men  made  of  rubber.  He  hid  under  the  bed  with  fear. 
On  the  27th  he  heard  frightful  voices.  He  wandered  about  in  fear  and  was 
constantly  without  sleep.  Admitted  September  2d,  he  is  without  fever,  con- 
gested, anxiously  disturbed,  trembles  like  an  aspen-leaf,  sees  crowds  of  ani- 
mals, and  hears  frightful  voices.  The  patient  is  a  tall,  powerful  man.  With 
the  exception  of  gastric  catarrh  and  enlargement  of  the  liver,  there  are  no 
vegetative  disturbances.  Pvilse,  70,  slow.  The  patient  receives  2  grams  of 
chloral  with  0.01  gram  of  morphine. 

He  sleeps  the  night  of  the  3d,  and  is  free  from  visual  hallucinations.  He 
still  has  hallucinations  of  hearing.  Known  and  unknown  voices  call  him  a 
wicked  fellow,  reproach  him  with  having  no  shirt.  He  passes  good  nights 
under  treatment  with  morphine  and  chloral. 

On  the  6th  the  voices  disappear  which  toward  the  end  he  had  heard  only 
just  before  going  to  sleep.  He  is  now  lucid  and  has  insight  into  his  disease. 
He  grows  stronger,  but  for  some  days  is  weak  and  troubled  with  tinnitus 
(cloudiness  and  redness  of  the  ear-drum).     Discharged  well  on  the  16th. 

2.  Hallucinations  of  the  Inebkiate  (Sensuum  Fallacia 

Ebeiosa). 

The  great  tendency  of  drinkers  to  develop  errors  of  the  senses, 
especially  of  vision,  is  well  known.     Usually  they  are  merely  ele- 


526  SPECIAL  PATHOLOGY  AND  THERAPY  OF  IKSAMTY. 

nientary  and  fragnientarv.  In  rare  cases  they  occur  in  great  number 
and  as  a  disconnected  hallucinatory  delirium  which  has  a  very  transi- 
tory character,  but  which  lasts  no  longer  than  a  few  hours.  Repeated 
alcoholic  excesses  and  caloric  influences  may  induce  them. 

The  elements  of  the  delirium  are  visual  and  auditory  hallucina- 
tions; their  content  is  frightful.  With  this  there  are  acusma  (con- 
fused noises  and  roaring)  and  precordial  distress.  Consciousness  is 
clouded  and  dreamy,  not  permitting  recognition  of  the  hallucinations; 
but  this  does  not  exclude  a  summary  memory  for  the  events  of  the 
attack. 

Serious  acts  of  violence  toward  others  are  possible  as  a  result  of 
the  state  of  consciousness  induced  by  hallucinations  and  illusions. 

Case  61.— Alcoholic  hallucinations.    A^'il'c-nu^•dcr. 

S.,  aged  3(j.  Like  his  wife,  an  excessive  drinker  of  wine  and  brandy. 
For  years  he  sufl'ered  with  bad  sleep,  dull  head,  tremor,  vomiting,  headache, 
and  dizziness  in  the  morning  on  waking.  He  was  always  brutal,  had  bt'come 
irritable  and  maltreated  his  wife,  and  had  even  threatened  to  kill  her. 

From  the  1st  to  the  8th  of  December  it  was  said  that  he  and  his  wife 
consumed  about  twelve  liters  of  brandy  and  were  drunk  almost  all  the  time. 
From  the  8th  to  the  16th  he  had  delirium  tremens  (violent  fear,  saw  proces- 
sions of  men,  robbers,  saints,  angels,  Christ,  animals,  and  heard  music). 

From  the  Kith  of  December  until  the  4th  of  January  he  was  free  from 
hallucinations,  but  he  felt  weak,  tremulous,  incapable  of  work,  had  a  cloud 
before  his  eyes,  slept  badly,  dreamed  of  robbers  that  tried  to  get  in  a  window, 
felt  dizzy,  dull  in  the  head,  had  no  appetite,  and  had  noises  in  his  ears. 

January  4th  he  took  his  son  to  some  relatives  about  two  hours  away  and 
there  drank  about  a  liter  of  wine,  and  on  his  way  home  one-half  or  three- 
fourths  of  a  liter.  On  leaving  the  saloon  his  head  was  on  fire  and  he  knew 
not  who  he  was;  saw  himself  surrounded  by  a  crowd  of  horses,  oxen,  and 
girls;  ran  awaT  in  fear,  and  reached  home  after  several  hours,  exhausted.  He 
had  some  reason,  still  spoke  to  his  wife,  drank  a  little  more  wine,  and  went 
to  sleep.  After  a  time  8.  started  up,  awakened  by  a  noise  of  men  crying  out; 
he  saw  robbers  at  the  window  pointing  guns  at  him,  and  then  a  cloud  came 
before  his  eyes. 

In  fright  he  sprang  from  the  bed,  took  his  loaded  gun,  more  dead  than 
alive  with  fear.  Then  his  consciousness  became  still  more  clouded,  and  he 
only  knew  that  he  heard  a  weak  detonation,  saw  then  two  reddish-yellow 
angels  at  the  window,  and  when  he  approached  them  found  his  wife  lying  in 
her  blood.  With  this  he  threw  open  the  door  of  the  maid's  room  and  called 
for  help,  saying  that  his  wife  had  shot  herself.  The  servants  had  heai'd  a  dis- 
pute; then  all  was  still.  After  awhile  they  heard  three  dull  blows,  then  the 
wife  saying:  "Jesus,  Victor,  what  are  you  doing;  are  you  crazy?"  Then 
came  the  shot.  The  wife  was  shot  through  the  head,  and  lived  only  a  few 
minutes. 

S.  thought  that  his  wife  had  shot  herself.  He  wept,  ran  about,  and 
seemed  abnoiTnal  to  those  around  him.  Care  was  taken  to  prevent  him  injur- 
ing himself.    The  officers  that  came  at  half-past  one  foimd  him  more  sensible, 


,      CHRONIC  INTOXICATIONS.  527 

but  a  little  anxious.  At  his  hearing  he  declared  tliiit  his  wife  had  shot  herself. 
His  unembarrassed,  indifferent  miinner  was  reniarUahlc. 

The  patient  is  livid,  the  veins  of  the  face  dilated,  tiie  eyes  circled,  the 
lids  edematous,  the  face  pulFy,  gait  unsteady,  hands  tiembjing,  sleep  restless, 
disturbed  by  dreams.  Physical  examination  reveals  slight  enlargement  of  the 
spleen  and  liver,  and  gastric  catarrh.  Patient  complains  of  dullness,  headache, 
noises  in  the  ear,  vertigo.  He  often  has  precordial  distress.  At  night  he 
hears  music  of  a  hand-organ,  talks  to  himself,  and  often  starts. 

In  the  daytime  he  was  silent,  sunken  in  thought,  apathetic,  and  showed 
neither  regret  nor  other  emotion.  Weakness  of  memory  and  mental  weak- 
ness in  general  were  unmistakable.  At  first,  S.  still  declared  that  his  wife  had 
shot  herself.  He  had  only  a  very  summary  memory  of  the  events  of  the  night 
of  the  tragedy.  Toward  the  end  of  February  he  felt  better  and  recalled  his 
hallucinatory  experiences,  began  to  doubt  that  his  wife  committed  suicide,  and 
to  think  that  perhaps  in  his  fear  and  drunken  hallucination  he  had  killed  her. 
Gradually  he  became  perfectly  clear  about  the  situation.  There  was  nothing 
pathologic  except  slight  weakness  of  intelligence;  monocrotic,  slow  pulse; 
slight  tremor  of  the  hands,  and  restless  sleep.  His  subjective  symptoms  were 
limited  to  noises  in  the  ear  and  weakness  of  memory.  He  could  not  bear  even 
small  quantities  of  wine;  for  when  he  took  it  he  immediately  had  a  curious 
feeling  in  his  head. 

3.  Alcoholic  Psychoses. 

JSTot  infrequently  distinct  psychic  disease-pictures  occur  in 
drinkers.  Not  all  these  diseases  have  specific  features.  Thus,  mel- 
ancholias and  manias  occur  which  differ  from  the  same  diseases  due 
to  other  causes,  only  in  that  the  organic  foundation  lends  them  a 
grave  idiopathic  character.  The  melancholias  areanainly  stuporous; 
the  manias  are  violently  congestive,  with  profound  disturhance  of 
consciousness,  or  they  present  a  reasoning  character. 

With  these,  however,  there  are,  upon  the  hasis  of  chronic  alco- 
holism, psychoses  that  are  quite  as  specific  as  delirium  tremens,  which 
never  develop  after  a  single  alcoholic  excess,  no  matter  how  extreme, 
but  which,  independently  of  any  such  excess,  develop  as  a  result  of 
any  somatic  or  psychic  accessory  cause  affecting  the  deteriorated  brain 
of  the  habitual  drinker. 

These  specific  alcoholic  psychoses  are: — 

(a)  Alcoholic  IfelancJwlia. 

This  is  distinguished  by  sudden  outbreak  and  an  acute  course, 
lasting  usually  from  eight  to  ten  days,  infrequently  a  few  weeks.  It 
is  further  distinguished  by  the  considerable  clouding  of  conscious- 
ness, the  numerous  hallucinations,  the  violent  precordial  distress, 
possibly  becoming  a  panphobia,  raptus  melancholicus,  attempts  at 
suicide,  and  rapid  subsidence,  with  only  summary  memory;  so  that 
to  the  convalescent  patient  the  disease  seems  like  a  bad  dream. 


528  SPECIAL  PATHOLOGY  AND  TIIERArY  OF  INSANITY. 

Owing  to  the  disturbance  of  consciousness  and  the  acute  course, 
there  is  no  systematization  of  delusions  or  connection  of  them  with 
self-accusation;  this  could  occur  only  in  protracted  cases.  The 
numerous  hallucinations  occurring  especially  during  states  of  fearful 
apprehensive  emotion  are,  in  part,  accusing  voices  (murderer;  thief; 
sexual  accusations,  as,  for  example,  being  infected;  threats  of  death 
and  imprisonment),  and,  in  part,  visions  (white  forms,  the  devil, 
ghosts,  masks,  animals,  usually  in  great  number).  The  latter  are 
more  episodic,  and  they  are  not  further  elaborated  in  the  delirium. 

Somatically  there  are  usually  signs  of  acute  alcoholic  intoxica- 
tion, chronic  alcoholism,  headache,  violent  congestion,  and  sleepless- 
ness. The  most  frequent  causes  are  emotions,  especially  fright,  and 
alcoholic  excesses.    The  prognosis  is  very  favorable. 

The  sleeplessness  and  fear  yield  to  opium  quite  as  readily  as  they 
do  in  delirium  tremens.  To  combat  the  congestion,  baths  with  ice- 
packs are  indicated,  and,  with  increased  heart-action,  digitalis. 

Case  62. — Alcoholic  melancholia. 

G.,  aged  49,  married,  baker.  His  father  was  a  drinker  and  he  himself 
has  been  given  to  drunkenness.  Of  late  years  he  had  become  irritable,  and 
during  the  last  few  months  had  slept  badly,  frequently  trembling  in  the  morn- 
ing. In  April  and  May  he  had  much  to  do,  with  cares  about  the  purchase  of  a 
house.  May  7th,  violent  fright  on  accoimt  of  a  chimney  burning  out.  There- 
after he  became  sleepless,  fearful,  wandered  about  profoundly  depressed,  and 
said  that  he  was  a  capital  criminal,  had  killed  his  child,  had  a  heart  of  stone, 
was  unworthy  to  have  his  Avife  near  him,  and  belonged  in  prison.  The  patient 
presented  marked  congestion  of  the  head,  tremor  of  the  hands,  and  at  times  on 
the  9th  and  10th  of  May  saw  multitudes  of  rats  and  mice,  did  not  sleep,  was 
much  excited,  anxious,  heard  himself  accused  of  having  violated  girls,  drimk 
the  blood  of  children,  and  that  he  was  therefore  destined  to  be  infamously  pim- 
ished.  He  awaited  the  coming  of  the  executioner,  was  in  fearful  fright,  so 
that  his  admission  to  the  clinic  became  necessary  on  May  16,  1880. 

Conscioiisness  is  decidedly  disturbed :  he  is  anxious,  delirious,  has  numer- 
ous visual  and  auditory  hallucinations,  sees  robbers,  the  devil,  hears  accusing 
voices  saying  that  he  is  a  villain,  dog,  an  on^mist,  has  seduced  girls,  had  com- 
merce with  animals,  and  must  be  biu-ned.  The  patient  says  he  is  guilty,  that 
he  has  lived  immorally,  has  compared  persons  of  high  standing  to  beasts,  and 
expects  an  ignominious  death. 

The  patient  is  of  medixim  height;  very  stout;  pulse  small,  120;  tem- 
perature, 37°  C.  Heart-sounds  dull,  hands  and  tongue  tremulous,  head  hot 
and  congested.  The  patient  falls  asleep,  but  is  immediately  wakened  by 
frightful  dreams.  At  times  panphobia,  affects  of  despair.  With  opium  and 
Avine  he  slept.  On  the  morning  of  the  18th  congestion  and  fear  Avere  some- 
Avhat  less.  The  patient  says  that  he  has  seen  much  fire  and  many  animals. 
He  had  been  in  Heaven,  then  had  floAvn  doAvn  like  a  bird  of  prey,  and  stopped 
on  the  point  of  a  spire.  He  had  descended  too  late  to  prevent  a  terrible  mis- 
fortune.    When  at  last  he  succeeded  in  loosening  himself,  Heaven  had  fallen 


CHRONIC  INTOXICATIONS.  529 

to  the  earth.  He  had  set  fire  to  the  whole  city  and  brought  misfortune  upon 
innumerable  men;  had  led  forth  numerous  children  bound,  and  caused  railroad 
accidents.  He  always  heard  voices  telling  him  to  ask  God  for  forgiveness; 
but  he  could  not  pray,  his  head  was  tilled  with  confusion.  He  must  have  a 
double;  consists  of  two  personalities.  He  hears  his  own  voice,  and  the  other 
does  everything  for  him.     In  his  imagination  he  runs  about  tlie  whole  house. 

With  opium  treatment  (up  to  0.15  gram  subcutanoously  twice  daily)  the 
patient  becomes  quieter,  sleeps  sufficiently,  and  gains  physically.  Toward  the 
end  of  May,  howfever,  he  was  still  anxious,  embarrassed,  hallucinated,  and  dis- 
turbed. The  people  scold  about  him  and  look  in  the  window  threateningly. 
He  feels  as  if  liis  liands  and  feet  had  been  cut  off.  His  double  had  murdered 
the  emperor  and  queen,  and  the  guilt  for  these  crimes  is  placed  on  him.  He 
occasionally  mistakes  a  fellow-patient  for  God,  who  reproaches  him  and  calls 
him  a  liar.  Another  patient  seems  to  him  to  be  the  Emperor  of  Russia,  and 
he  fears  to  be  taken  for  a  nihilist  and  punished.  He  complains  that  his  head 
is  full  of  frightful  thoughts  that  he  cannot  banish.  He  often  thinks  that  all 
is  deception,  disease,  but  he  cannot  help  himself. 

June  2d,  after  a  few  good  nights,  the  hallucinations  cease.  The  patient 
begins  with  a  little  help  to  gain  complete  insight  into  his  disease.  Now  and 
then  he  is  still  troubled  with  frightful  illusions.  For  some  time  the  patient  is 
still  exhaiisted,  sleeps  much,  and  improves  rapidly  with  the  use  of  tonics  and 
frictions. 

On  June  26th,  when  he  was  able  to  give  an  account  of  what  he  remem- 
bered of  his  disease,  he  said-  that  suddenly  on  May  9th  the  disease  began  with 
violent  fear  and  confusion.  It  was  as  if  God  himself  were  judging  him,  and  he 
were  damned.  From  that  time  on  he  had  very  few  clear  moments.  Those 
around  him  at  one  time  seemed  frightful,  at  other  times  like  God;  and  he  had 
murdered  wife  and  daughter.  It  was  as  if  a  veil  had  been  lifted  from  his  eyes 
when  both  appeared  before  him  at  a  visit  on  June  4th.  He  had  but  vague 
memory  of  all  other  events  of  the  disease.  On  June  30th  he  was  discharged 
recovered. 

(h)  Mania  Gravis  Potatorum. 

The  specific  maniacal  disease-picture  which  develops  upon  the 
basis  of  chronic  alcoholism  corresponds,  in  large  part,  with  that  de- 
scribed by  other  authors  as  mania  ambitiosa,  congestiva,  gravis 
(Schule).  I  have  observed  it  only  on  the  basis  of  chronic  alcoholism, 
and  I  find,  in  the  grouping  of  the  symptoms,  detail,  and  course, 
peculiarities  that  make  it  seem  to  me  to  be  specific.  It  is  never  pre- 
ceded by  a  melancholic  period.  The  outbreak  is  sudden  with  clear 
signs  of  congestion ;  or  it  is  more  like  the  initial  maniacal  excitement 
of  dementia  paralytica,  differing  from  it  only  in  that  the  psychic 
weakness  in  mania  gravis  (alcoholic)  is  not  so  evident. 

The  initial  symptoms  are  increasing  irritability,  change  of  char- 
acter, fluxions,  disturbed  sleep,  sometimes  absence  of  sleep,  restless- 
ness, and  tendency  to  wander  about  and  indulge  excessively  in  alcohol. 
Yery  soon  there  is  decided  elevation  of  self-feeling.     The  disease 


:,30  SPECIAL  TATHOLOGY  AND  TITER APY  OF  TXSAMTY. 

quickly  reaches  tlic  height  of  furious  mania,  or  attains  this  degree 
tlirough  a  stage  of  maniacal  excitement.  This  differs  from  benign 
maniacal  exaltation,  in  the  presence  of  marked  increase  of  self-feel- 
ing, in  the  groat  irritahilit}^  which  may  lead  to  terrible  violence" 
toward  others,  in  tlie  boastfiüness  and  the  tendency  to  buy  and  waste, 
and  in  vagal)ondage  and  brutal  recklessness;  also  often  in  eroticism, 
which  nuiy  be  directed  toward  daughters  or  show  n  ii\  the  opqn  street. 
Delusions  of  grandeur  occur  early. 

At  tlie  heiglit  of  the  furious  mania  the  profound  idiopathic  and 
organic  nature  of  the  process  is  indicated  by  the  great  confusion,  dis- 
turbance of  consciousiiess,  irritability,  enormous  increase  of  self- 
feeling,  and  the  motor  acts  being  almost  exclusively  impulsive;  also 
frequently  by  salivation,  tremor  of  the  lips  and  tongue,  facial  pa- 
resis, myosis  or  unequal  pupils,  and  disturbance  of  speech  due  to 
ataxia  of  the  lips. 

AVith  this,  in  all  cases  there  are  associated  delusions  of  grandeur 
which  equal  in  their  outlandislmess  those  of  the  paralytic,  though 
they  are  not  so  desiiltory  or  so  varied.  A  religious  content  pre- 
dominates. The  patients  declare  themselves  to  be  God,  Christ,  an 
emperor,  enormously  rich,  etc. 

Sometmies  there  are  also  desultory  delusions  of  persecution, 
especially  of  poisoning;  or  the  delusion  of  marital  infidelity.  At 
the  height  of  the  disease  there  are  numerous  hallucinations,  at  first 
almost  exclusively  of  sight  (devil,  angels,  divine  persons,  paradise); 
later,  of  hearing  with  corresponding  content. 

The  maniacal  acts  are  distinguished  by  their  frightful  brutality 
and  destructiveness;  by  howling,  crying,  raving,  smearing,  and  tearing; 
and  temporarily  and  episodically  there  are  attacks  of  angry  mania. 

Somatically  in  most  cases  there  is  pronounced  congestion  with 
sleeplessness.  At  the  height  of  the  disease  there  are  exacerbations 
and  remissions.  In  the  remissions  the  picture  becomes  one  of 
maniacal  exaltation  with  persistence  of  grand  delusions,  with  a  mania 
to  collect  objects  and  be  busy,  in  which  the  clothing  and  bedding  are 
sacrificed;  in  many  cases,  however,  is  present  the  picture  of  psychic 
enfeeblemcnt. 

The  height  of  the  disease  lasts,  on  an  average,  some  weeks.  In 
favorable  cases  sleep  returns  and  the  excitement  subsides.  The  re- 
missions become  more  marked ;  the  excitement  passes  through  a  stage 
of  angry  mania,  which  is  followed  by  a  condition  of  mental  enfeeble- 
ment,  with  phenomena  which  are  the  last  echoes  of  maniacal  exalta- 
tion and  have  the  characteristics  of  moria  and  reasoning,  or  by  a 
condition  of  profound  mental  exhaustion,  with  demented  brutality 


CHRONIC  INTOXJOATrONS.  531 

and  irascibility,  before  recovery  is  aLiaincd.  However,  if,  may  happen 
that  at  the  acme  of  the  disease  the  condition  grows  worse,  passing 
into  acute  delirium,  rapidly  followed  by  death. 

In  other  cases  the  disease  becomes  chronic;  the  excitement 
gives  2ihice  to  increasing  mental  weakness;  the  affects  take  on  a 
child isli  character,  and  from  the  height  of  grand  delusions  the  pa- 
tients often  suddenly  pass  to  childish  weeping.  Occasionally  tlx're 
are  still  angry  explosions,  or  congestive  maniacal  attacks.  The  pro- 
found disturbance  of  the  mental  and  motor  centers  is  more  and  Tuore 
clearly  shown  in  the  continued  impulsive,  purposeless  destructive- 
ness,  and  smearing.  The  delusions  of  grandeur  become  weaker  and 
more  fragmentary;  affects  disappear  or  are  expressed  in  a  silly  man- 
ner. Even  at  this  stage,  recovery  is  possible;  the  psychic  organ,  so 
profoundly  injured,  does  not  come  forth  intact, — the  patient  is  de- 
fective, mentally  weakened,  and  remains  very  irritable  to  alcohol 
and  emotional  stimuli.  For  the  most  part,  a  profound  degenerative 
process  in  the  brain  is  the  result:  progressive  dementia  with  de- 
structive impulses.  With  this,  there  is  rapid  loss  of  weight,  slow 
monocrotic  pulse,  weak  heart-sounds,  relaxed  arteries,  subnormal  tem- 
perature, boils,  phlegmons — due  to  the  smearing  and  rolling  about 
in  straw — that  cannot  be  made  to  heal.  Then  finally  there  may  be 
facial  palsy,  inequality  o:^  pupils,  unilateral  sweating,  and  awkward- 
ness and  uncertainty  in  the  movements  of  the  limbs. 

Death  occurs  after  a  few  months  or  a  year  as  a  result  of  decu- 
bitus, colliquative  diarrhea,  or  hypostatic  pneumonia,  with  the  patient 
in  a  state  of  mental  and  physical  marasmus. 

The  prognosis  is  doubtfu.1.  In  one-half  the  cases,  but  only  in 
the  first  stage,  recovery  takes  place — of  course,  often  enough  with 
mental  defect. 

Autojisy  in  advanced  cases  shows  hyperostosis  cranii  Avith  disappearance 
of  the  diploe ;  anemia  of  the  pia,  clouded  as  a  result  of  lymph-stasis ;  edema  of 
the  brain;  commencing  atrophy  (narrowing  gyri).  The  orifices  of  the  vessels 
gape  and  the  vessels  are  dilated.  The  ventricles  are  somewhat  dilated  and  the 
ependyma  sometimes  granular. 

The  disease-picture  at  the  beginning  and  at  the  height  of  the  disease 
indicates  the  presence  of  vasoparetic  hyperemia,  and  in  this  stage  a  recovery 
is  still  possible.  In  later  stages  there  is  emigration  of  elements  of  the  blood 
into  the  perivascular  spaces',  with  lymph-stasis,  and  retrograde  changes  in  the 
brain. 

In  the  initial  stages,  prolonged  baths  with  ice-packs,  injections 
of  opium  and  ergotine,  are  to  be  recommended,  and,  when  the  heart's 
action  is  increased,  digitalis.    During  the  transition  to  the  secondary 


533  SPECIAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

stage  supporting  treatment  with  opium  and  quinine  is  indicated.  In 
the  final  stages,  rest  in  bed,  warmth,  stinnüation  of  the  circulation, 
good  food,  and  care  to  prevent  decubitus  are  necessary. 

Case  (So. — ^lania  gravis  potatorum.    Death. 

S.,  agecl,3G,  (lay-lalxiior.  He  had  an  inaanc  sisLcr.  He  was  given  to 
drink  from  his  j-outli.  lie  was  very  sensual,  and  a  rascal  who  stole  in  order 
to  drink.  Fifteen  years  l)efore  he  was  caught  in  an  act  of  burglary.  He 
received  several  severe  blows,  witli  a  wound  on  the  head.  He  was  always  very 
choleric  ami  iniiil<-tcnipered.  Nine  years  ago  lie  married  and  liad  five  cliildion, 
four  of  wliom  died  soon  after  birth.  For  years,  with  other  signs  of  clironic 
alcoholism,  lie  has  been  extremely  irritable  and  brutal. 

Tlie  middle  of  August.  1878,  the  patient  became  sleepless,  restless,  sold 
his  small  property  for  nothing,  stopped  work,  struck  his  wife,  and  threatened 
to  burn  the  house  when  she  talked  to  him  about  his  conduct.  He  spoke  un- 
reasonably, and  constantly  boasted  of  his  strength  and  wealth,  and  thought 
by  a  rich  marriage  and  business  to  increase  liis  fortune  enormously.  He  fol- 
lowed women  in  the  streets. 

On  admission  he  presented  profound  disturbance  of  consciousness,  im- 
pulsive restlessness,  ran  about  blindly,  and  began  to  destroy  and  strike  about 
himself  when  he  was  not  allowed  to  depart.  He  boasted  of  his  sexual  power, 
declared  that  he  was  enormously  rich,  and  would  now  marry  several  beautiful 
women.  Great  mental  weakness.  His  ideas  were  disconnected  and  without 
motive. 

The  patient  presented  the  appearance  of  a  drinker:  face  dusky,  with 
dilated  vessels;  circled  eyes,  expression  confused,  facial  innervation  unequal, 
tremor  of  the  lips  and  hands.  Arteries  rigid;  pulse  strong,  jumping,  9(J,  in- 
creasing to  130  with  exercise.  The  apex-beat  is  external  to  the  line  of  the 
nipple.  The  left  ventricle  is  hypertrophied.  In  place  of  the  second  sound 
over  the  left  ventricle  and  the  aorta  there  is  a  blowing  murmur. 

The  patient  is  sleepless,  sings,  whistles,  and  destroj'S  impulsively  every- 
thing that  falls  in  his  hands.  He  rolls  in  his  straw  and  boasts  of  his  enormous 
strength;  he  can  turn  over  thirty  railway  cars  with  one  hand  or  stop  a  rail- 
way train  at  full  speed.  This  vmheard-of  strength  comes  from  God.  Great 
change  of  mood;  usually  gay,  episodically  angry.  He  changes  suddenly  from 
the  height  of  joy  with  singing  of  Te  Deums  to  childish  weeping,  and  then  speaks 
of  hanging  himself.  The  mania  presents  the  features  of  mental  A\'eakness  and 
confusion,  indicated  also  by  the  childish  emotional  state. 

The  patient  is  constantly  sleepless,  and  no  result  is  obtained  from  digi- 
talis, opium,  'morphine,  chloral,  beer,  wine,  or  brandy.  The  patient  wanders 
about  dreamily,  pounds  on  the  doors,  smears,  and  destroys  everj'thing  in  a 
truly  impulsive  way. 

His  grand  delusions  (descended  from  God,  he  knows  not  how;  is  himself 
God,  captain,  president,  the  first  of  all  the  world)  become  more  and  more  dis- 
connected and  more  and  more  affected  by  dementia  until  they  finally  disappear 
in  a  childish  gay  state  of  feeling,  which  stands  in  striking  contrast  with  the 
mental  deterioration.  Physical  decay  also  comes  on  in  December.  There  is 
subnormal  temperature  (36°  C).  The  pulse  becomes  small,  CO,  weak,  and  at- 
tacks of  unilateral  sweating  in  the  domain  of  the  left  cervical  sympathetic 


CHEONIC  INTOXICATIONS.  533 

with  dilatation  of  the  vessels,  and  elevation  of  temperature  over  the  cor- 
responding half  of  the  head,  are  observed. 

The  left  pupil  becomes  wider,  the  left  facial  is  less  innervated,  and  there 
are  diarrhea  and  slight  symptoms  of  collapse,  with  decided  loss  of  general 
nutrition  and  progressive  anemia  (rest  in  bed,  wine,  brandy).  The  patient 
grows  more  and  more  demented,  but  the  dementia  lemains  gay.  Jle  believes 
himself  in  Heaven  and  as  healthy  as  an  angel.  When  not  in  bed  he  wanders 
about,  smears,  destroys  everything  that  comes  to  his  hand,  has  the  mania  of 
collecting  everything,  eats  rags,  goes  to  the  spittoons,  etc.  Progressive  de- 
terioration, decubitus;    death,  July  4,  1879. 

Autopsy:  Hyperostosis  of  the  bones  of  the  skull,  sutures  complete,  ex- 
ternal hydrocephalus.  Diffuse  milky  cloudiness  and  thickening  of  the  pia  over 
the  frontal  and  parietal  regions.  Pia  edematous  and  anemic.  The  vessels  at 
the  ba*e  atheromatous.  The  surface  of  the  brain  is  swollen  and  the  convolu- 
tions are  flattened ;  the  cortex,  olive-green.  The  brain  is  anemic,  edematous, 
and  the  vessels  markedly  dilated.  The  ventricles  are  dilated  and  filled  with 
clear  serum.  The  ependyma  is  viscous,  thickened,  but  without  granulations. 
Lungs  edematous.  In  the  upper  lobe  of  the  right  lung,  flaccid  hepatization. 
The  left  ventricle  is  much  hypertrophied  (three  centimeters  thick),  heart- 
muscle  pale,  slightly  fatty.  Aortic  valves  shrunken  and  thickened.  Aorta 
dilated,  with  stifi'ened  walls  due  to  atheroma.  Spleen,  liver,  and  kidneys  show 
venous  hyperemia. 

(c)  Hallucinatory  InsaniUj. 

This  is  a  rather  frequent  disturbance,  having  specific  features, 
which  Marcel  recognized,  and  which  is  well  described  by  Nasse  as 
the  '^persecutory  insanity  of  the  insane  drinker." 

In  the  first  place,  the  short  stage  of  incubation  emphasized  by 
Nasse  is  noteworthy.  It  is  marked  by  headache,  vertigo,  disturbed 
sleep,  signs  of  congestion,  and  the  usually  sudden  outbreak  of  the 
actual  psychosis,  with  frightful  hallucinations,  especially  of  hearing. 
In  the  disease-picture  itself,  the  hallucinations  of  sight,  which  are 
rarely  wanting,  are  to  be  emphasized.  They  are  incorporated  in  the 
delirium,  and  manifest  a  certain  degree  of  persistence.  Por  the  most 
part,  they  have  a  frightful  content  and  lead  to  violent  reactive  fear. 
With  this  there  may  be  fantastic  forms  and  visions  of  animals  of 
indifferent  content.  Hallucinations  of  taste  and  smell  are  infrequent. 
These  likewise  have  an  unpleasant  content,  and  lead  to  delusions  of 
poisoning.  The  hallucinations  of  hearing  are  the  most  important. 
With  remarkable  frequency  these  have  an  obscene  content :  the  patients 
hear  insulting  remarks  about  the  condition  of  their  genitals  (no  penis, 
impotence),  or  sexual  insults  and  threats  (pederasty,  bestialit}^,  mas- 
turbation, etc.). 

The  deliria  are  those  of  persecution  and  grandeur.  The  former 
are  the  most  important  and  are  primary.    These,  too,  have  very  fre- 


534  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

quently  a  sexual  content  and  are  concerned  with  marital  infidelity  or 
the  immoral  conduct  of  others,  with  which  still  further  delusions  of 
persecution  (threats  of  murder,  kidnaping,  etc.),  with  corresponding 
hallucinations  (criminal  approaching  execution,  etc.),  may  be  asso- 
ciated. The  paralgic  and  hypcresthetic  states  so  frequent  in  chronic 
alcoholism  may  also  lead  to  delusions  of  physical  persecution  (elec- 
tricity, etc.). 

As  a  result  of  jDersecutory  delusions  and  hallucinations  there  are 
very  frequently  violent  reactive  attacks  of  fear.  As  Nasse  found,  in 
other  respects  these  patients  are  remarkably  devoid  of  emotional 
feeling. 

Delusions  of  grandeur  may  episodically  appear  even  in  the  be- 
ginning, but,  as  a  rule,  they  occur  in  the  course  of  tlie  disease  with 
corresponding  hallucinations.  They  are  about  great  riches,  royal  posi- 
tions, etc.  (one  of  my  patients  received  a  message  from  God  telling 
him  that  he  would  be  made  burgomaster).  Less  frequently  than 
Nasse  I  have  observed  religious  delusions  (Christ).  The  accompany- 
ing somatic  disturbances  belong  to  chronic  alcoholism.  The  course 
is  a  rapid  one  to  recovery  or  to  terminal  states  of  mental  weakness. 
The  prognosis  of  the  acute  case  is  good;  doubtful,  when  the  course  is 
chronic.  As  a  rule,  only  recovery  with  defect  can  be  obtained  (mental 
weakness  with  incomplete  insight  into  the  disease  after  disappearance 
of  delusions  and  hallucinations) ;  but  perfect  recovery  is  not  impossible. 

Case  G-i. — Alcoholic  persecutory  hallucinatory  insanity. 

W.,  aged  33,  married,  official,  comes  of  healthy  parents.  He  developed 
well,  ^Yas  talented  and  free  from  disease.  During  the  last  ten  years  he  had 
indulged  in  alcoholic  excesses  (wine,  beer),  and  had  eaten  irregularly.  For 
some  years  he  has  been  intolerant  of  alcohol  and  heat.  Since  the  beginning  of 
1881  he  had  sufl'ered  with  stomach  trouble,  morning  vomiting,  and  trembling 
on  rising  in  the  morning.  In  the  summer  of  1881  he  fell  by  stumbling  over  the 
trunk  of  a  tree,  and  became  immediately  confused.  One  hour  later  he  fell 
imconscious,  and  thereafter  was  maniacal  for  three  days.  Amnesia  for  this 
period.     After  coming  to  himself,  he  recovered  entirely. 

Since  the  spring  of  1882  he  had  had  much  overwork,  many  cares,  annoy- 
ance in  his  occupation,  and  had  been  driven  to  drink  more  than  usual.  Of  late 
his  stomach  trouble  and  tremor  had  decidedly  increased.  In  July  he  felt  ex- 
cited, sometimes  dull,  and  had  scotomas.  Since  the  beginning  of  August  Ik; 
had  slept  badly,  complained  of  noises  in  his  ears,  noises  at  night,  barking  of 
dogs,  feeling  of  oppression  in  the  chest,  congestion  of  the  head,  and  difficulty 
in  working.  Those  about  him  often  noticed  that  he  stared  before  him,  was 
suspicious,  fearful,  and  unusually  irritable. 

September  3d  the  patient  took  a  trip  to  Budapest  on  business.  To  fellow- 
travelers  he  seemed  peculiarly  retiring,  irritated,  and  excited.  As  he  said 
aiter  recovery,  he  thought  on  this  journey  that  innocent  conversation  in  the 


CHRONIC  INTOXICATIONS.  535 

car  was  directed  at  him.  He  thought  lie  heard  himself  called  deserter  (the 
patient  had  not  fulfilled  his  military  duties  because  he  was  absent  from  the 
country)  and  onanist.  On  arrival  in  Budapest  he  felt  very  uncomfortable,  un- 
certain, and  embarrassed.  In  the  evening,  while  eating  in  the  garden  of  the 
hotel,  he  heard  an  order  read  for  his  aiiest,  and  some  one  asked  for  him.  He 
was  pursued  as  a  deserter.  It  seemed  remarkable  to  him  that  at  tho  same 
time  he  remained  calm.  He  hastened  to  his  room  and  tried  to  go  to  sleep. 
He  could  not  sleep.  From  all  sides  he  heard  his  past  and  his  present  spoken 
of  and  criticised,  as  if  through  telephones.  He  also  heard  that  he  had  been 
marked  with  the  nickname  of  "black  dog." 

On  the  4th  he  felt  that  his  head  was  much  benumbed.  He  was  much  em- 
barrassed and  could  scarcely  trust  himself  on  the  street,  awaiting  from  hour 
to  hour  his  arrest;  the  more  because  he  had  heard  that  the  order  for  his 
arrest  was  in  the  newspaper. 

On  the  night  of  the  5th  there  was  a  frightful  experience:  he  saw  re- 
volting, threatening  forms,  dark  shadows,  fly  through  the  room,  and  voices 
that  criticised  his  actions  and  called  him  "pig,  vagabond,  onanist;  there's  a 
fellov/  who  is  falling  again."  He  was  very  much  excited  and  beside  himself 
about  these  low  accusations.  When  he  went  out  on  the  street  on  the  5th  he 
noticed  that  he  was  an  object  of  general  attention.  From  all  sides  he  heard 
himself  called  "pig,  villain,  black  dog."  He  fled  to  Ofen,  but  decided  a,t  the 
railroad  station  to  return  to  Gratz.  Whue  sitting  in  the  train  he  heard 
officers  ask  the  conductor  whether  the  "black  dog"  was  there  or  not.  At  the 
stations  there  were  large  crowds  of  people  who  wanted  to  see  the  "black  dog." 
He  crouched  in  his  seat,  especially  because  stones  were  tlirown  at  the  window, 
and  when  the  train  stopped  he  heard  the  words:  "Hurry  or  the  crowd  will  tear 
him  to  pieces."  In  neighboring  compartments  he  heard  conversation  about  his 
immoral  life.  On  arrival  in  Gratz  he  hurried  to  put  himself  under  the  protec- 
tion of  the  police,  who  sent  him  to  the  clinic. 

In  a  state  of  fear  the  patient  arrives.  He  is  without  fever,  presents 
symptoms  of  gastric  catarrh,  slight  icterus,  enlargement  of  the  liver,  tremor  of 
the  tongue  and  hands,  reduced  sensibility  in  the  feet  reaching  to  the  ankles. 
His  nights  are  sleepless,  and  hallucinations  and  delusions  continue.  He  hears 
noises  and  cries  as  coming  from  a  crowd;  voices  which  had  already  pursued 
him  in  Budapest.  They  spoke  in  a  Schwabian  dialect  (his  native  place  is 
Schwabia)  ;  announced  to  him  that  he  must  undergo  public  disgrace  for  his 
sexual  crimes.  The  patient  protests  verbally  and  in  writing  against  these  in- 
famous accusations,  is  anxious,  excited,  and  asks  not  to  be  escorted  by  officers, 
and  demands  official  protection  against  his  persecutors.  In  the  night  he  is 
constantly  the  subject  of  consideration  (voices  of  pursiiers,  officers) ;  he  fre- 
quently jumps  up  in  fright  and  complains  of  precordial  distress. 

Treatment  with  opium  is  begun  on  September  10th.  His  nights  become 
quieter;  the  voices  subside.  On  September  19th  he  began  to  correct  his  de- 
lusions, saying  that  he  must  have  had  a  kind  of  persecutory  delusion  in  his 
head.  The  patient  is  still  exhausted,  slightly  neurasthenic,  but  recovers  under 
tonic  treatment  and  opiates,  that  favor  sleep,  by  the  end  of  September. 

His  statement  concerning  his  memory  of  the  attack  confirms  the  details 
given  in  the  history,  and  also  the  predominant  sexual  tinge  of  the  hallucina- 
tions, as  well  as  the  absence  of  visual  hallucinations.  There  were  no  amnesic 
periods. 


536  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(d)  Alcoholic  Paranoia. 

Alcoholic  paranoia  is  infrequent.  Its  delusions  are  essentially 
those  of  persecution,  but  there  is  occasionally  transformation  to  delu- 
sions of  grandeur.  Tluit  which  characterizes  alcoholic  paranoia  is 
the  sexual  nucleus  of  the  delusions.  The  patients  hear  all  sorts  of 
sexual  accusations  and  think  they  are  called  sodomists,  pederasts,  vio- 
laters,  etc.,  and  are  hated  by  everybody.  With  this  there  are  the 
somatic  and  psychic  sjrmptoms  of  alcoholism,  the  specific  hallucina- 
tions, and  especially  the  visual  hallucinations  foreign  to  other  forms  of 
persecutory  paranoia.  Besides,  the  features  of  mental  weakness 
early  appearing  in  the  disease-picture  are  noteworthy.  The  rough- 
ness and  irritability  manifested  in  brutal  reaction  toward  the  sup- 
posed persecutors,  which  render  these  patients  extremely  dangerous, 
also  deserve  attention. 

Case  65. — Alcoholic  paranoia. 

C,  aged  53,  single,  tailor,  was  arrested  for  arson,  and  after  police  exami- 
nation was  sent  as  insane  and  dangerous  to  the  psychiatric  clinic  in  Gratz. 
He  said  that  all  his  trouble  was  due  to  the  accusation  of  his  enemies,  the 
burgomaster  and  the  woman  of  whom  he  had  rented  his  apartments.  It  was 
all  a  plan  of  his  persecutors,  who  wished  to  destroy  him  and  render  him  for- 
ever incapable  of  action.  He  had  called  down  the  hatred  of  the  woman  a  year 
ago,  because  lie  had  denounced  her  to  the  police  as  having  secretly  given  birth 
to  a  child  ^vhieh  she  had  murdered  and  hidden  in  the  garden.  Though  he  had 
seen  the  criminal  in  the  act  and  it  was  spoken  of  publicly,  the  police  had  not 
paid  any  attention  to  his  accusation.  Soon  thereafter  the  burgomaster  told 
him  he  must  marry  a  prostitute  pregnant  by  the  burgomaster's  brother,  a 
command  which  he  refused  with  indignation.  Since  this  time  he  had  been 
the  object  of  persecution  by  the  woman  of  whom  he  rented,  as  well  as  of  the 
head  of  the  Commune.  They  followed  him  step  by  step,  chased  away  his 
customers,  and  accused  him  of  sexual  inmiorality.  At  night  he  heard  them 
speaking  about  him.  Among  other  things,  they  said  he  was  a  hypocrite,  that 
he  secretly  committed  debauches,  was  impotent,  etc. 

Before  this  woman  became  his  enemy  lie  had  noticed  that  she  had  cast 
an  eye  on  him.  Slie  had  repeatedly  said  tha.t  slie  wished  to  come  to  him, 
for  she  could  no  longer  live  with  her  husband  because  he  had  intimate  and 
criminal  relations  with  his  own  daughter.  The  patient  thinks  that  the  woman 
has  become  his  enemy  because  he  has  refused  her  propositions,  and  that  she 
has  since  turned  to  the  burgomaster.  He  heard  them  say  that  from  jealousy 
they  hung  about  near  him  to  spy  lipon  him  and  watch  him.  When  he  de- 
nounced the  woman  to  the  police  he  noticed  that  the  body  of  the  child  had 
been  dug  up  and  hidden  in  an  unknown  place.  In  this  w^ay  he  explained  the 
lack  of  success  of  his  accusation.  He  was  scarcelj'  shut  up  before  he  heard  in 
prison,  day  and  night,  the  voices  of  his  two  enemies.  Evidently  they  had  al- 
lowed themselves  to  be  imprisoned  with  him  in  order  to  spy  on  him  and  shame 
him.     The  content  of  their  conversation  was  essentially  obscene.     They  talked 


CHRONIC  INTOXICATIONS.  537 

about  his  gallant  adventures  and  about  his  suspected  impotence,  "  because 
nothing  came  out  of  it." 

The  patient's  father  was  a  drinker  of  strong  spirits.  Several  brothers 
and  sisters  died  at  an  early  age,  probably  of  convulsions.  The  patient  was  of 
low  mental  development  and  early  gave  himself  to  drink,  lie  has  evidently 
had  chronic  alcoholism  for  years.  Bad  sleep  for  montlis,  unpleasant  dreams, 
frequent  awal<ening  in  friglit,  occasional  visions  of  animals  at  night. 

The  patient  is  intellectually  much  weakened  and  is  pleased  to  find  in  the 
hospital  protection  from  his  persecutors,  since  he  does  not  hear  them.  Con- 
fused expression,  weakness  of  the  right  lower  facial,  tremor,  restless  nights, 
awakening  in  fright  after  dreams  of  frightful  animals  a.nd  persecution.  He 
sticks  fast  to  his  delusions.     The  patient  was  sent  to  an  asylum  in  his  district. 

(e)  AlcolioUc  Paralysis. 

Sometimes  chronic  alcoholism  terminates  in  a  condition  similar  to 
paralytic  dementia.  In  contrast  with  the  ordinary  cases  of  this  dis- 
ease, which  etiologically  have  nothing  at  all  to  do  with  alcoholic  ex- 
cesses, or  in  which  alcoholic  excesses  are  only  a  subsidiary  cause,  in 
harmony  with  Schule,  from  a  differential  diagnostic  standpoint,  we 
may  emphasize :  the  acute  course  of  usually  only  a  few  months ;  the 
extreme  and  usuall}^  general  tremor  of  the  patients ;  the  frequency  of 
apoplectiform  and  epileptiform  attacks;  the  frequency  of  anesthesias 
or  hyperesthesias  limited  to  the  lower  extremities;  the  intense  head- 
ache in  the  beginning  and  during  the  course  of  the  disease;  the 
relative  infrequency  of  grand  delusions;  the  remains  of  earlier 
delusions  of  marital  infidelity;  the  frequent  and  clearly  alcoholic 
hallucinations  of  sight;  and  the  slighter  disturbance  of  speech,  for 
the  most  part  limited  to  ataxia  of  the  lips  and  less  characterized  by 
syllabic  stumbling. 

With  this  there  is  the  more  favorable  course,  in  that  such  cases 
of  alcoholic  paralysis  (pseudo-paralysis)  may  recover  entirely,  or  at 
the  worst  with  defect. 

In  cases  that  came  to  autopsy  I  found  the  usual  pathologic 
changes  of  paralysis;  but  it  is  remarkable  that  the  granulations 
otherwise  always  found  in  the  ependyma  were  wanting. 

Case  66. — Alcoholic  paralysis.    Eecovery. 

S.,  aged  31,  miller,  admitted  January  18,  1876.  Father  Avas  a  drinker  and 
mother  had  convulsions.  The  patient  was  healthy,  except  for  small-pox,  which 
he  had  when  he  was  a  child.  He  early  gave  himself  to  drink,  and  for  years 
he  had  been  irritable,  suffered  with  headache,  vertigo,  and  slept  badly.  For 
some  months  he  had  been  forgetful,  negligent  in  his  work,  and  done  all  sorts 
of  crazy  things.  For  some  days  he  had  been  excited,  sleepless,  wandered 
about,  and  expressed  grand  delusions.  On  admission  there  was  great  disturb- 
ance of  consciousness.     He  did  not  know  where  he  was  and  thouoht  he  was  in 


538  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

a  mill.  His  thouglit  is  disconnected  and  confused,  and  lie  says  that  lie  is  the 
owner  of  a  mül  and  Avill  marry  the  widow  of  a  miller;  that  he  has  a  fortune 
of  100,000  florins  and  will  rebuild  the  mill  in  a  most  beautiful  way. 

On  the  head  there  are  a  few  superfkial  scars  in  the  skin;  no  trace  of 
lues;  the  right  side  of  the  face  is  less  innervated  than  the  left;  fibrillary 
twitching  of  the  facial  muscles;  tremor  of  the  lips  and  tongue;  speech  con- 
siderably disturbed  by  labial  ataxia,  though  without  stumbling  on  syllables; 
gait  unsteady, "slightly  vacillating. 

Pulse  very  slow,  GS;  left  pupil  reacts  more  slowly  than  tlie  right.  The 
vegetative  organs  normal.  No  alterations  of  sensibility.  Patient  Avanders 
about,  talks  of  silly  projects  of  grandeur,  intends  to  buy  the  hospital  to  re- 
construct it,  is  expecting  the  miller's  widow,  who  is  in  love  with  him  because 
he  is  such  a  fine,  powerful  man.  He  is  easily  diverted  from  his  thought.  The 
motor  distui-bances  change,  increasing  on  the  whole.  On  the  24th  and  28th  an 
epileptiform  attack  (general  convulsions,  with  loss  of  consciousness)  ;  increas- 
ing dementia  with  intercurrent  states  of  excitement.  Sleep  improves  under 
the  use  of  baths  and  chloral.  Injections  of  morphine  are  given  for  the  states 
of  excitement.  April  20th,  another  epileptiform  attack.  In  the  course  of 
May  consciousness  grew  clearer,  the  motor  disturbances  passed  away,  exee])t 
for  the  dilatation  of  the  left  pupil  and  twitching  of  the  muscles  of  the  left 
cheek  that  was  manifest  in  movements  of  expression  and  speech.  The  patient 
gains  insight  into  his  disease,  and  he  himself  ascribes  it  to  over-indulgence  in 
spirits.  His  mental  weakness  also  passes  away,  and  the  patient  becomes  en- 
tirely capable  of  his  employment  again,  and  since,  up  to  January  13,  1877,  no 
return  of  symptoms  were  observed,  he  was  discharged.  The  recovery  has  been 
maintained. 

4.  Alcoholic  Epilepsy. 

The  brain  changes  due  to  alcoholic  excesses  may  also  lead  to 
epileps3^  Factors  which  favor  the  origin  of  epilepsy  in  drinkers  are 
not  infrequently  found  in  hereditary  predisposition,  convitlsions  in 
childhood,  and  injuries.  The  statement  by  Magnan  that  alcoholic 
epilepsy  occurs  only  in  drinkers  of  absinthe  is  not  correct.  It  may 
be  caused  by  all  kinds  of  intoxicating  drinks. 

Since  epilepsy  depends  functionally  upon  a  lasting  abnormal 
innervation  of  certain  cerebral  centers  (so-called  epileptic  change), 
it  is  clear  that,  like  delirium  tremens,  it  cannot  be  induced  by  a 
single  alcoholic  excess,  no  matter  how  extreme,  but  only  by  long-con- 
tinued excesses.  The  occurrence  of  an  epileptic  attack  under  the 
exciting  influence  of  drunkenness  always  proves  that  this  epileptic 
change — i.e.,  epileps}^ — pre-existed,  just  as  the  return  of  epileptic 
attacks  in  epileptics  are  frequently  enough  induced  by  the  influence 
of  occasional  indulgence  in  alcohol. 

If  alcoholic  epilepsy  become  once  established,  then  the  most 
important  exciting  causes  of  the  attacks  are  alcoholic  excesses.  About 
10  per  cent,  of  alcoholics  present  epileptic  attacks.  They  are,  in  gen- 
eral, late  manifestations  of  chronic  alcoholism. 


CHRONIC  INTOXICATIONS.  539 

Frequently  these  epileptic  attacks  are  only  incomplete,  in  that 
they  effect  only  single  groups  of  muscles  or  one  side  of  the  body.  It 
is  further  noteworthy  that  they  are  usually  inaugurated  and  accom- 
panied by  violent  congestion.  Too,  consciousness  frequently  is  not 
entirely  lost.  But,  besides  these  incomplete  attacks,  there  are  others 
which  differ  in  no  respects  from  the  vertiginous  or  convulsive  picture 
of  epilepsy.  For  the  diagnosis,  the  manner  of  the  beginning  of  these 
attacks  is  of  greater  importance  than  their  form,  in  that  the  attacks 
occur  at  long  intervals,  but  are  repeated,  when  they  occur,  in  con- 
nection with  an  alcoholic  excess.  Quite  ordinarily  such  a  series  of 
attacks  is  followed  by  psychic  disturbances  in  the  form  of  epileptic 
delirium,  or  a  dreamy  or  stuporous  state  of  clouded  consciousness. 
Sometimes  a  simultaneous  complication  with  delirium  tremens  or 
hallucinations  is  observed.  With  the  occurrence  of  alcoholic  epilepsy 
the  intellectual  degeneration  of  the  patient  makes  rapid  progress. 

The  prognosis  is  very  unfavorable,  partly  on  account  of  the 
disease  itself,  and  partly  because  of  the  repeated  alcoholic  excesses, 
which  intensify  the  predisposition  and  provoke  new  attacks.  Bro- 
mide of  potassium  seems  useful  in  alcoholic  epilepsy;  but  numerous 
drinkers,  without  the  administration  of  potassium  bromide,  remain 
free  from  attacks  during  their  stay  in  the  hospital,  with  its  favorable 
hygienic  surroundings,  and  especially  owing  to  their  cessation  of 
indulgence  in  spirits. 

Case  67.- — Alcoholic  epilepsy.  Combined  delirium  tremens  and 
epileptic  delirium. 

P.,  aged  37,  merchant,  not  predisposed,  much  given  to  excessive  drinking 
since  youth.  He  had  delii'ium  tremens  in  1859,  and  in  1860  severe  typhoid 
with  cerebral  symptoms.  Nine  years  ago,  after  alcoholic  excesses,  he  had  his 
first  epileptic  attack.  Such  attacks  recurred  about  every  four  months,  usually 
after  excess  in  drinking,  and  were  single.  They  began  with  violent  headache 
and  were  followed  by  stuporous  states  lasting  several  hours,  in  which  the 
patient  was  anxious,  saw  threatening  forms,  animals,  and  flames.  None  had 
occurred  in  five  years  imtil  October  22,  1876,  after  renewed  alcoholic  excess. 
In  the  morning  while  drawing  on  his  boots  the  patient  suddenly  felt  a  violent 
headache;  it  grew  dark  before  his  eyes,  and  he  fell  unconscious.  The  attack 
was  repeated  in  the  afternoon.  In  the  evening  the  patient  was  brought  in  a 
stuporous  state  to  the  hospital,  his  tongue  bleeding  where  it  had  been  bitten. 
He  gives  general  statements  about  himself  correctly,  seems  anxious,  unsettled, 
and  excited.  General  tremor;  no  fever;  pulse,  88,  soft,  slow.  Heart-sounds 
dull,  liver  enlaa-ged.  Patient  sleeps  a  little.  On  the  23d  the  patient  comes  to 
himself,  astonished  to  find  himself  in  the  hospital.  His  memory  extends  no 
further  than  the  morning  of  the  22d. 

In  the  course  of  the  afternoon  the  patient  began  to  see  birds,  mice,  rats, 
rubber  men,  all  trying  to  lift  him  in  the  air.     Increasing  restlessness,  violent 


540  SrECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

tremor.  In  spite  of  chloral,  sleepless  imtil  the  24th,  with  innumerable  visions 
of  animals.  On  the  24th,  at  7  o'clock  in  the  evening,  epileptic  attack,  with 
biting  of  the  tongue.  Thereafter  coinplii-ating  the  delirium  tremens  there 
was  an  epileplir  delirium,  profound  disturbance  of  consciousness,  terrible  fear, 
blind  raving,  and  attempts  to  get  out.  The  patient  sees  murderers,  is 
butchered,  his  head  lies  on  the  bench  and  he  feels  great  gaping  wounds  in  his 
body.  At  intervals  again  innumerable  visions  of  animals.  He  thinks  he  is  in 
a  saloon,  drinks  beer,  holds  his  empty  glass  to  the  waiter,  and  scolds  because 
the  waiter  does  not  come  immediately.  Chloral  without  effect.  On  the  25th 
0.15  gram  of  extract  of  opium  subcutaneously.  The  patient  sleeps  the  entire 
night  of  the  2Gth,  quickly  becomes  lucid,  and  has  summary  memory.  He  says 
that  for  the  first  time  he  had  such  frightful  delirious  attacks  nine  years  ago, 
and  five  years  ago,  which  occurred  after  epileptic  attacks  and  lasted  about 
five  days.  The  patient  recovers  rapidly  under  small  doses  of  niiiuui,  and  is 
discharged  October  30th. 


CHAPTER  II. 
Morphinism. 

MoEPHiXE^  used  to-day  in  so  many  cases  to  relieve  pain,  espe- 
cially in  the  form  of  subcutaneous  injections,  in  many  instances  gives 
not  only  relief  from  pain,  but  also  induces  a  feeling  of  intellectual 
and  physical  well-being  which  augments  the  power  for  intellectual 
and  physical  work  while  its  effect  lasts.  Thanks  to  these  properties, 
morphine  is  not  only  a  sedative  (narcotic,  hj^pnotic),  but  it  is  also 
a  stimulant  and  a  means  of  inducing  pleasurable  feeling.  This  latter 
effect  of  morphine  seems  to  be  especially  marked  in  individuals  of 
neuropathic  constitution  (Erlenmeyer).  The  continued  use  of  mor- 
phine is  by  no  mpans  harmless.  Like  the  continued  and  excessive 
use  of  alcohol,  it  induces  symptoms  of  chronic  intoxication,  and  has 
such  a  powerful  influence  upon  nutrition  and  the  functions  that,  in 
those  accustomed  to  its  use,  dangerous  conditions  arise  when  the 
u.sual  dose  is  diminished  or  suddenly  stopped  (symptoms  of  absti- 
nence). Owing  to  the  sufferings  which  occur  immediately  with  ab- 
stinence, the  need  and  desire  for  morphine  as  a  stimulant,  and  also 
owing  to  the  profound  weakness  of  the  will  which  occurs  as  one  of 
the  results  of  abuse  of  morphine,  the  attempt  to  free  such  patients 
of  their  evil  demon  is  difficult,  and  it  can  be  accomplished,  as  a  rule, 
only  in  a  hospital. 

Almost  every  morphinist  reaches  a  condition  when  the  sufferings 
due  to  chronic  intoxication  outweigh  the  pleasant  effects,  and  the 
latter  can  be  obtained  only  temporarily  or  as  a  result  of  very  large 
doses  of  the  drug.  Under  such  circumstances  medical  interference 
becomes  imperative;    for  the  health  and  life   of  the   patient  are 


CHRONIC  INTOXICATIONS.  541 

threatened  by  grave  dangers.  The  etiologic  conditions  favoring  the 
origin  of  morphinism  arc  principally  a  peculiar  constitution  which 
experiences  a  pleasurable  clfcct  from  the  administration  of  juorphino. 
The  immediate  causes  of  its  use  are  found  in  all  diseases  accom- 
panied by  pain  or  sleeplessness  when  they  last  long  enough.  If  the 
physician  lightly  leave  this  drug  at  the  disposition  of  his  patient,  or 
if  the  patient  is  in  a  position  to  obtain  morphine  easily,  then  he  falls 
a  victim  to  morphinism. 

Symptomatology  of  Mokpiiinism. 

In  describing  the  symptoms,  those  of  chronic  intoxication  and 
those  resulting  from  abstinence  are  to  be  distinguished. 

Symptoms  of  Intoxication. — These  rarely  occur  before  three 
months  in  persons  of  good  resistive  power  (healthy,  not  burdened), 
often  much  later,  and  even  then  they  are  so  mild  that  the  real  ab- 
normal change  in  the  nerve-centers  manifests  itself  only  with  ab- 
stinence. There  seems  to.  be  in  these  cases  conditions  like  those 
found  in  alcoholism,  the  severe  and  degenerative  effects  of  which 
require  a  more  or  less  abnormally  predisposed  personality.  In  any 
event,  it  is  not  the  daily  dose  nor  the  duration  of  the  indulgence  that 
is  decisive,  but  the  individuality.  The  symptoms  of  chronic  intoxica- 
tion are  psychic  and  somatic.  We  are  here  interested  principally 
with  the  psychic  symptoms. 

Morphine  never  injures  so  profoundly  the  psychic  organ  as  does 
alcohol,  but  I  have  never  seen  a  morphinist  that  was  psychically 
intact.  Intelligence,  it  is  true,  is  practically  spared,  but  the  highest 
mental  functions  —  character,  ethic  feeling,  self-control,  mental 
energy,  and  force — always  suffer.  The  fully  developed  morphinist 
is  an  individual  weak  in  character  and  will  and  without  energy,  who 
should  receive,  under  criminal  prosecution,  the  benefit  of  attenuating 
circumstances,  and  who  in  the  care  of  his  interests  and  duties  should 
alwaj^s  be  given  help. 

In  severe  cases  Ave  find,  in  addition,  weakness  of  memory,  espe- 
cially defect  in  the  power  of  exact  reproduction,  difficulty  of  intel- 
lectual activity  that  may  reach  the  degree  of  torpor,  occasionally 
psychic  depression  reaching  even  marked  dysthymia  and  tcedium  vitcB, 
great  emotionality,  and,  in  general,  profound  deficiency  of  resistive 
power  to  affects;  and  besides,  there  may  be  episodically  nervous  rest- 
lessness, excitement,  even  attacks  of  fear  due  to  vasomotor  causes, 
and  occasionally  visual  hallucinations. 

A  great  part  of  the  somatic  symptoms  may  be  referred  to  the  influence 
of  morphine  to  lessen  secretions  and  act  as  a  vasomotor  constrictor.    Owing 


542  SPECIAL  FATHOLOCY  AND  THERAPY  OF  INSANITY. 

to  lessened  salivary  secretion  there  is  troublesome  dryness  in  the  month  and 
throat;  lessened  secretion  of  the  sebaceous  glands  causes  drj-ness  and  hard- 
ness of  the  skin;  and  stagnation  of  the  secretions  in  the  glands  favors  the 
formation  of  boils.  Owing  to  the  defective  secretion  of  the  stomach  and 
pancreas,  digestion  and  assimilation  sulTcr,  and  also  defecation,  as  a  result  of 
(liminished  peristalsis.  The  secretion  of  urine  is  also  usually  lessciied;  albu- 
minuria is  not  infrequent.  Amenorrhea  also  often  occurs  early,  but  ovulation 
is  rarely  interrupted,  as  numerous  cases  of  prcgnaiu-y,  in  spite  of  ainenorrlica, 
prove.     Aspcrmia  is  also  observed. 

On  the  other  hand,  it  is  remarkable  to  note  that  the  secretion  of  per- 
spiration is  often  much  increased.  Numerous  motor  disturbances  are  added : 
reduced  muscle-tone,  tremor,  disturbance  of  co-ordination  reaching  the  degree 
of  marked  ataxia,  weakness  of  the  sphincters,  myosis,  weakness  of  accommo- 
dation, cystospasm,  distiirbance  of  innervation  of  the  heart  (asthenia  cordis, 
attacks  resembling  angina  pectoris).  In  part,  we  may  refer  to  vasomotor 
spasm  the  reduced  turgor  vitalis,  the  pale,  sunken  cheeks,  the  coolness  of  the 
skin,  and  the  need  of  warmth  observed  in  these  patients.  The  sensory  sphere 
also  manifests  its  implication  in  hyperesthesias,  neuralgias,  and  paresthesias. 
Frequently  libido  sexualis  is  reduced  very  early,  and  in  time  is  lost.  In  the 
advanced  stages  of  intoxication  anorexia  and  obstinate  sleeplessness  come  on. 
Fever  is  not  infrequent  in  the  form  of  slight  febrile  temperatures  in  the  even- 
ing (sometimes  even  presenting  a  picture  of  the  typhoid  state;  but  the  tem- 
perature rarely  rises  above  3S.3°  C),  or  in  the  form  of  intermittent  febrile 
attacks  which  cannot  be  distinguished  clinically  from  a  genuine  intermittent 
fever  of  the  quotidian  or  tertian  type.  The  result  of  all  these  troubles  is  in- 
creasing marasmus,  senium  prcccox,  which  sometimes  as  a  result  of  fatty 
degeneration  of  the  myocardium  and  cardiac  paralysis  leads  to  a  sudden  end. 

Symptoms  of  Abstinence. — These  vary  in  accordance  Avith  the  sudden 
or  gradual  suspension  of  the  morphine.  The  differences  are  really  quantitative. 
Symptoms  of  gradual  removal  may  occur  even  with  a  decided  reduction  of  the 
dose.  The  first  symptoms  of  relative  abstinence  or  of  hunger  for  morphine 
are  yawning,  itching  of  the  skin,  nervous  restlessness,  anxietj',  vomiting,  and 
diarrhea.  With  this  there  are:  extreme  weakness,  tremor,  neuralgias  in  the 
extremities  and  the  viscera,  chills,  great  need  of  warmth;  profuse  perspiration, 
very  imstable  vasomotor  activity,  vacillating  pulse;  general  increased  reflex 
excitability,  sensorial  hyperesthesia,  floating  spots  before  the  eyes,  and  noises 
in  the  ears  which  may  become  hallucinations;  agrypnia,  disturbance  of  con- 
sciousness with  defective  correction  of  errors  of  the  senses  and  sudden  result- 
ing perverse  acts ;  painful  restlessness,  anxious  confusion,  dysthymia  that  may 
become  tccdium  vitcc;  a  peculiar  disturbance  of  memory  (incorrect  localization 
in  time  of  past  events).  There  may  even  be  states  resembling  delirium 
tremens,  as  in  total  abstinence;  and  it  is  interesting  (Eehm)  that  even  in  a 
long  course  of  removal  subcutaneously,  a  formal  hallucinatory  delirium  may 
occur;  as  in  one  of  my  cases,  in  which  it  came  on  late,  after  presumably  the 
state  of  abstinence  had  been  passed.  This  delirium  is  mainly  frightful,  with 
numerous  hallucinations;  also  with  hallucination  of  taste  and  smell,  and  hos- 
tile interpretation  of  the  numerous  abnormal  cutaneous  sensations  (delusion 
of  physical  persecution,  persecution  with  electricity). 

Symptoms  due  to  sudden  total  abstinence  occur  after  about  six  hours. 
The  patients  become  relaxed,  weak,  incapable  of  standing,  have  symptoms  like 


CHRONIC  INTOXICATIONS.  543 

those  of  rbolera  nostras,  profuse  sweating,  general  tremor,  painful  anxiety, 
restlessness  going  on  to  weeping,  raving,  and  violent  demand  for  morphine, 
which  immediately  removes  all  the  troubles  due  to  abstinence,  and  the  patient 
may  not  hesitate  to  commit  a  crime  to  get  the  drug. 

Not  infrequently,  following  these  symptoms  of  abstinence,  there  is  an 
hallucinatory  delirium  lasting  several  days — a  true  delirium  of  inanition, 
M'hich,  on  account  of  its  numerous  analogies  with  alcoholic  delirium  tremens, 
may  well  be  called  the  delirium  tremens  of  morphinism  (numerous  visions  of 
animals;  episodically  also  obscene  deliria,  mainly  of  frightful  content, 
agrypnia,  tremor).  In  severe  cases  the  symptoms  of  abstinence  and  inani- 
tion may  reach  a  point  of  dangerous  cardiac  and  respiratory  weakness, 
collapse,  and  coma,  and  make  it  absolutely  a  vital  indication  to  administer 
morphine. 

Symptoms  of  intoxication  and  abstinence  in  the  form  -of  elementary 
psychic  disturbances,  anorexia,  and  asthenia,  may  exist  a  long  time,  even 
months,  after  the  drug  has  been  withdrawn. 

Tkeatment  of  Moephinism. 

The  methodic  withdrawal  of  the  poison  under  medical  super- 
vision in  a  hospital  is  the  first  indication.  Withdrawal  is  only  con- 
tra-indicated in  cases  in  which  an  incurable  and  extremely  painful 
malady'  demands  the  use  of  the  drug.  Under  such  circumstances 
morphine  is  the  lesser  evil. 

The  method  that  the  author  has  used  many  years  is  that  of  grad- 
ual withdrawal.  Sudden  withdrawal  is  cruel^  not  without  danger,  and 
increases  the  danger  of  relapses.  We  first  -determine  the  minimum 
amount,  i.e.^  the  daily  dose,  with  which  the  patient  can  get  on.  This 
first  diminution  may  be  very  considerable  (the  half  or  the  third  of 
the  usual  daily  dose)  ;  for  morphinists  consume  much  more  than  they 
require.  From  this  reduced  dose  we  proceed  carefully  during  the 
course  of  ten  or  twenty  days,  until  the  dose  is  reduced  to  nothing, 
while  replacing  the  morphine,  in  accordance  with  the  individuality, 
by  morphine  internall}^,  or  still  better  by  injections  of  hydrochlorate 
of  codeine,  or  of  the  aqueous  extract  of  opium;  or  finally  by  the  ex- 
tract of  opium  internally.  Eest  in  bed;  good,  rich  food;  especially 
milk  with  cognac,  etc.,  for  there  is  usually  aversion  to  meat;  eating 
during  the  times  when  the  patient  feels  well  immediately  after  an 
injection;  rich  wine  in  liberal  doses;  and  baths  of  63°  F.,  aid  the 
patient  to  endure  the  sufferings  of  the  withdrawal. 

The  state  of  the  heart  must  always  be  watched.  To  overcome 
agrypnia  bromides,  3  grams,  with  laudanum  (Erlenmeyer)  are  useful, 
as  are  also  sometimes  amyl  hydrate  and  trional.  Chloral  hydrate 
should  be  avoided.  The  withdrawal  of  the  last  drops  of  morphine 
often  costs  very  dear.    Much  of  this  is  psychic.    It  is  often  possible  to 


544  SPECIAL  PATHOLOGY  AND  THP^RAPY  OF  INSANITY. 

bring  calm  with  injections  of  distilled  water  unknown  to  the  patient. 
When  later  the  patient  is  told  of  this  trick  it  increases  his  confidence. 
With  the  withdrawal  of  the  morphine  the  cure  is  by  no  means 
ended.  The  causes  which  in  the  first  place  render  the  patient  a 
morphinist  must  be  removed,  the  last  traces  of  intoxication  and  ab- 
stinence must  disappear,  and  the  person  must  be  made  morally  and 
physically  capable  of  resistance.  For  this  purpose,  weeks  and  even 
months  of  after-treatment  may  be  required.  If  the  fulfillment  of 
these  indications  is  impossible,  then  relapses  are  inevitable. 

Case  68. — ^Eorphinism. 

C.  P.,-  aged  29,  physician's  wife,  tainted  family.  Her  husband  gave  her 
four  years  ago  repeated  injections  of  morphine  for  severe  toothache.  She 
experienced  with  this  a  feeling  of  great  well-being.  Thereafter  she  had  all 
sorts  of  trouble  and  cares  and  also  very  frequently  toothache,  and  being 
the  wife  of  a  physician  who  had  remedies  in  the  house,  she  could  easily  obtain 
morphine;  thus  she  became  a  morphinist.  She  took  large  quantities,  and, 
when  gradually  symptoms  of  chronic  intoxication  caine  on,  she  also  began  to 
take  cocaine,  which  had  first  been  given  to  her  in  an  attempt  to  withdraw  the 
morphine.  The  patient  cannot  state  the  size  of  her  doses.  During  the  last 
few  months  she  had  always  taken  a  thimbleful  of  morphine  and  the  same 
amount  of  cocaine  dissolved  in  water,  and  had  injected  this  as  she  required  it. 
There  have  been  symptoms  of  intoxication  for  a  year  (agrypnia,  anorexia, 
amenorrhea,  anemia,  tremor,  loss  of  flesh).  She  could  not  get  on  without 
morphine,  and  the  moment  the  usual  dose  was  not  injected  at  the  proper  time 
she  had  symptoms  of  abstinence  in  the  form  of  dreadful  discomfort,  feeling  of 
great  weakness,  anxiety,  depression.  During  the  last  few  weeks  she  had  had 
occasional  attacks  of  anxiety  and  frightful  auditory  and  visual  phantasms 
(effect  of  cocaine?),  Avith  even  attacks  of  hallucinatory  deliriinn. 

April  20,  1887,  the  patient  came  to  the  nervous  clinic  at  Gratz  to  undergo 
a  cure  by  withdrawal.  She  brought  a  considerable  quantity  of  morphine  and 
cocaine  with  her.  The  cocaine  was  stopped  immediately  and  without  injury, 
and  she  was  given  0.2  gram  of  morphine  daily. 

Tall,  powerfully  built,  but  thin  and  anemic;  skin  faded,  dry,  pale;  color 
muddy;  muscle-tone  diminished,  relaxed  attitude;  nervous,  depressed  expres- 
sion and  action.  Pupils  narrow;  tremor  of  the  hands ;  patellar  reflexes  much 
reduced.  Heart-sounds  pure,  strong;  no  vegetative  disturbances;  urine  with- 
out albumin;    temperature  normal. 

Ordered:  rest  in  bed,  wine,  and  rich  food.  The  minimum  dose  with 
which  she  could  get  on  was  found  to  be  0.22  gram  of  morphine.  This  dose  of 
morphine  was  gradually  reduced  (on  AprU  27th  it  had  reached  0.12  gram;  on 
May  2d,  0.03  gram  daily).  From  May  2d  on  aqueous  extract  of  opium  in- 
ternally, with  reduction  of  the  morphine  to  0.01  gram.  From  May  7th  on, 
injections  of  water.  The  symptoms  of  abstinence  were  limited  to  fatigue, 
depression,  and  mental  indisposition.  Agrypnia  was  overcome  with  4  grams 
of  bromide  with  20  drops  of  laudanum. 

A  few  days  after  the  withdrawal  of  the  morphine,  rapid  improvement  of 
general  nutrition  to  the  extent  of  several  pounds,  improvement  of  the  turgor 


CHRONIC  INTOXICATIONS.  545 

vitalis  and  appetite,  restoration  of  sleep  with  a  general  state  of  comfort,  and 
disappearance  of  the  fatigue.  On  May  21st  there  was  nothing  abnormal 
mentally  or  physically  to  be  observed.  The  patient  looks  well  and  as  though 
she  had  grown  younger.  Absolutely  no  more  need  of  morphine.  Though  Mrs. 
P.  was  discharged  May  23d,  she  has  remained  well  and  has  had  no  relapses. 

Case  69. — Morphinism. 

Mrs.  K.,  aged  40,  wife  of  an  official,  of  neuropathic  family,  said  to  have 
been  healthy  previously.  She  fell  ill  with  violent  emotional  excitement  after 
her  first  puerperium,  with  hysteria  gravis.  She  was  given  injections  of  mor- 
phine. This  overcame  the  convulsions  and  the  hysteric  pain,  but  the  patient 
could  not  give  up  the  drug  without  having  immediately  severe  hysteric  at- 
tacks. At  first  she  bore  the  drug  well,  but  after  a  few  years  the  menses 
stopped.  Still  she  had  children  (ten  years  ago  and  six  years  ago).  The  last 
child  was  weakly  and  died,  soon  after  birth,  with  convulsions.  Libido  sexualis 
was  early  lost.  Since  some  years  there  has  been,  with  a  daily  dose  of  mor- 
phine of  0.25  to  0.5  gram  subcutaneously,  loss  of  flesh.  The  patient  felt  weak, 
exhausted,  and  incapable  of  her  household  duties.  She  had  chilly  feelings, 
vague  neuralgic  troubles,  palpitation,  tremor,  and  in  1884  for  a  long  time 
attacks  of  intermittent  fever,  which  were  referred  to  malaria.  Sleep  con- 
tinued good. 

On  account  of  the  troubles  mentioned,  the  patient  decided,  on  April  28, 
1883,  to  submit  to  a  cure  by  withdrawal  in  the  nervous  clinic.  She  is  of 
middle  height,  reduced  in  flesh  and  muscle-tone.  The  deep  reflexes  can 
scarcely  be  elicited.  The  pupils  are  narrow;  pulse  weak;  heart-tones 
muffled;  tremor  of  the  hands  and  tongue;  dry,  cool  skin;  anemia;  anorexia; 
urine  free  of  albumin.  Temperature,  36.9°  C.  The  minimum  dose  she  could 
bear  was  0.35  gram  of  morphine  daily. 

Ordered:  rest  in  bed,  forced  feeding  (milk).  An  attempt  to  reduce  the 
morphine  at  first  causes  globus,  clonic  spasm  of  the  diaphragm,  anxious  rest- 
lessness. With  the  help  of  aqueous  extract  of  opium  internally,  it  was  pos- 
sible by  May  11th  to  reduce  the  morphine  to  0.1  gram.  From  May  18th  the 
patient  was  given  only  distilled  water  and  extract  of  opium  internally  up  to 
0.15  gram.  With  the  elimination  of  the  morphine  there  was  a  decided  im- 
provement in  nutrition.  The  menses,  which  had  ceased  for  ten  years,  returned 
on  May  22d,  and  were  normal.  There  are  slight  hysteric  attacks.  Under  the 
use  of  valerianate  of  zinc  and  extract  of  opium  they  disappear,  and  conva- 
lescence continues  undisturbed. 

June  6,  1882,  the  patient  returned  to  her  family.  She  used  still  for  some 
time  these  remedies,  and  had  only  now  and  then  slight  hysteric  attacks. 
There  was  no  desire  for  morphine.  After  a  sojoui-n  in  the  country  she  pre- 
sented herself  in  October,  1885,  in  blooming  health  and  spirits.  Menses 
normal. 

November  27, 1886,  another  confinement.  In  the  puerperium  (eight  days) 
violent  fright,  severe  hj^steric  attacks.  The  physicians  gave  injections  of  mor- 
phine (0.02  gram)  daily.  On  January  26,  1887,  the  patient  herself  came  re- 
questing a  new  cure.  The  withdrawal  was  successfully  accomplished  within  a 
few  days  with  the  internal  administration  of  opium.  Since  this  she  has 
remained  well. 


PART  FIFTH. 

Brain  Diseases  with   Predominating  Psychic 
Symptoms. 


CHAPTER 


Acute   Delirium   (Transudative   Hyperemia  in  Transition  to  Acute 
Periencephalitis). 

By  this  term,  derived  from  a  specially  prominent  symptom  and 
the  course  of  the  disease,  psychiatry  designates  a  grave  and  usually 
fatal  cerebral  disease,  in  which,  along  with  great  disturbance  of 
motility  and  the  general  system,  those  of  the  psychic  sphere  occupy  the 
foreground.  At  the  autopsy  there  are  always  changes  recognizable 
with  the  unaided  eye,  even  though  they  are  not  strictly  uniform. 

They  consist  of  congestion  of  the  brain  and  its  membranes.  The  hyper- 
emia extends  usually  also  to  the  spinal  cord.  The  hyperemia  is  frequently 
reduced  and  covered  during  the  latter  days  or  hours  of  lite  by  the  occurrence 
of  edematous  exudations.  The  general  appearance  at  the  autopsy  is  that  of 
venous  stasis  in  the  cerebrum.  The  brain  expands,  and  the  cortex  seems 
swollen.  White  streaks  often  follow  the  course  of  the  large  vessels  in  the 
pia  mater,  due  to  the  lymph-stasis  in  the  sheaths  of  the  vessels. 

The  microscopic  examination  reveals  the  evidence  of  blood-stasis,  with 
enormous  extravasation  of  elements  of  the  blood  as  a  result.  The  lymph- 
sheaths  appear  distended  with  white  blood-corpuscles,  among  which  red  cor- 
puscles are  not  infrequently  found.  Here  and  there  capillary  extravasations 
may  be  found.  The  lymph-stasis  extends  through  the  sheaths  of  the  vessels: 
on  the  one  hand,  into  the  lymph-spaces  of  the  pia;  on  the  other  hand,  into 
the  system  of  Deiters's  cell  network,  and  even  into  the  periganglionic  space. 

Cloudy  swelling  of  the  ganglion-cells  is  frequently  found.  Aside  from  the 
cerebrimi,  we  frequently  find  hj^postatic  congestion  of  the  lungs;  the  heart 
relaxed;  the  cardiac  muscle  soft,  pale,  fatty,  or  granular;  the  blood  of  a  re- 
markable dark  color  and  A^cry  liquid.  Fürstner  has  called  attention  to  the  oc- 
currence of  granular  waxy  degeneration  of  the  voluntary  muscles,  like  that 
observed  in  typhoid  fever,  typhus,  and  other  severe  acute  diseases. 

The  causes  of  the  disease  are  numerous,  but  they  have  this  in 
common:    they  are  direct  injurious  influences  affecting  the  brain. 

(546) 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       547 

Probably  in  all  cases  the  initial  change  is  in  the  vasomotor  system, 
and  the  initial  hyperemia  of  the  disease-process  arises  out  of  vascular 
paralysis.  The  disease  afEects  almost  with  equal  frequency  males  and 
females,  and,  as  a  rule,  in  middle  life.^  The  actual  exciting  causes 
are  emotional  excitement,  alcoholic  excesses,  extreme  mental  strain, 
caloric  influences;  hut  much  more  important  are  the  immediate,  hut 
predisposing,  causes  of  mental  and  physical  overstrain  in  the  struggle 
for  existence,  years  of  trouble,  drunkenness,  insufficient  food,  the 
Aveakening  effect  of  severe  confinements  and  diseases,  and  the  changes" 
incident  to  the  climacteric.  In  many  other  cases  there  have  been  cere- 
bral shock  due  to  head-injury  or  sunstroke;  typhoid  with  cerebral 
complications;  or  indefinite  cerebral  or  psychic  diseases  in  earlier 
years  that  have  left  behind  evident  results.  At  least  the  frequent 
hyperostosis  of  the  skull,  the  chronic  clouding  and  thickening  of  the 
pia,  and  the  circumscribed  atrophies  of  the  cortex,  so  frequently 
found  in  patients  that  have  died  in  acute  delirium,  indicate  such 
a  basis. 

In  by  far  the  majority  of  cases  of  my  observation  there  has  been, 
besides,  hereditary  predisposition  to  nervous  disease  in  persons  espe- 
cially irritable  in  their  emotions  and  in  their  vasomotor  functions. 

Too,  as  a  result  of  the  weakening  effect  of  typhoid,  of  delirium 
tremens,  or  of  furious  mania  in  a  decrepit  brain,  this  acute  delirium 
may  develop.  It  may  also  occur  as  a  complication  of  dementia  para- 
lytica, or  of  hysteria,  when  one  of  the  exciting  causes  mentioned  is 
active. 

When  these  etiologic  facts  are  considered,  the  assumption  sug- 
gests itself  that  the  pernicious  character  of  the  cerebral  hyperemia 
that  constitutes  the  disease  is  founded  in  the  pre-morbid  character  of 
the  brain,  and  that  acute  delirium  is  a  peculiar  form  of  reaction  to  a 
hyperemic  process  in  a  burdened  or  exhausted  brain,  the  vascular 
tone  of  which  is  profoundly  reduced.  While  the  pathogenesis  points 
to  influences  reducing  vascular  tone  and  indicates  that  the  h3^peremia 
is  originally  arterial  and  due  to  lessened  resistence,  the  further  course 
indicates  early  change  of  the  condition  to  that  of  venous  hyperemia 
induced  by  the  slowing  of  the  circulation  in  the  passively  dilated 
vessels,  in  connection  Avith  early  occurrence  of  weakness  of  the  heart's 
action.  The  direct  result  of  venous  h5rperemia  is  exudation  of  ele- 
ments of  the  blood  into  the  lymph-paths  of  the  pia  and  the  brain,  a 
result  that  may  be  favored  by  congenital  delicacy  of  the  vessels,  or 


^  Of  45  primary  eases  in  my  observation,  22  were  men,  ranging  in  age 
from  30  to  47;    and  23  were  women,  ranging  in  age  from  27  to  46  years. 


54S  FJPECIAT.  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

disturbance  of  nutrition  of  their  walls^  clue  to  inanition,  alcoliolio. 
excesses,  etc.  Later  on,  pressure  symptoms  appear  with  those  due 
to  irritation.  At  times  there  seems  to  be  partial  absorption  of  the 
exudate  (remissions),  but  the  constantly  recurring  fluxions  (exac- 
erbations) cause  renewed  exudations,  until  finally  absorption  and 
removal  of -waste-products  from  the  brain  are  no  longer  possible. 

The  fact  that  when  this  point  is  reached  recovery  but  seldom 
occurs  is,  in  part,  explained  by  the  pre-existing  clouding  and  thicken- 
ing of  the  pia  (occlusion  of  the  lymph-vessels),  perhaps  also  by  the 
primitive  condition  of  these  vessels  (Arndt)  ;  and,  in  part,  by  the 
existence  of  hyperostosis  of  the  skull  (narrowing  of  the  vascular 
passages),  in  connection  with  which  the  finding  of  Hertz  is  suggest- 
ive (abnormal  narrowness  of  the  jugular  foramen);  but  the  early 
insufficiency  of  the  hearths  action  is  of  great  importance,  due  to  pre- 
existing fatty  degeneration  in  cases  that  develop  as  a  result  of  inani- 
tion, alcoholism,  or  of  disturbances  of  nutrition  (cloudy  swelling) 
occurring  in  the  course  of  the  malady,  so  often  accompanied  by  an 
extreme  elevation  of  temperature. 

The  final  termination  of  the  whole  process  is  complete  venous 
stasis  in  the  brain,  with  which  there  may  stul  be  enormous  transuda- 
tion (edema).  In  these  patients  death  occurs,  with  increasing  symp- 
toms of  cerebral  pressure,  in  sopor  or  as  a  result  of  paralysis  of  the 
heart. 

Clixical  Aspect  of  the  Disease. — The  initial  symptoms  of 
acute  delirium  are  those  of  violent  hyperemia  with  symptoms  of 
irritation  of  the  psychic  and  motor  centers,  to  which  are  soon  added 
symptoms  of  cerebral  pressure.  These  latter,  when  the  exciting  cause 
has  been  intense  and  the  brain  is  very  vulnerable,  may  follow  upon  the 
cause  immediately  and  stormily,  or  they  may  develop  gradually  during 
a  few  days  or  weeks. 

The  patients  complain  of  headache,  of  a  feeling  as  if  the  head 
were  splitting,  of  heat,  congestion,  dullness  as  if  intoxicated,  and  of 
difficulty  of  thought.  They  often  have  a  premonition^  of  severe 
brain  disease.  They  become  irritable,  excited,  often  anxious,  morose, 
and  complain  of  great  apprehension.  The  mental  inhibition,  which 
may   at   times  become   stupor,   is   often  felt  to   be  painful.     Objec- 


*  Compare  Jehn,  wlio  in  four  cases  examiiipd  by  him  found  fatty  degen- 
eration, thickening,  proliferation  of  the  nuclei  of  the  adventitious  tissue,  de- 
posits of  globules  of  fat,  and  pigment. 

^  Two  of  my  patients  in  the  very  beginning  diagnosticated  inflammation 
of  the  brain  which  was  to  prove  fatal. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       549 

tively  there  are  signs  of  congestion;  disturbed^  confused,  expres- 
sion; narrowing  of  the  pupils;  uncertain,  slightly  staggering  gait; 
bad  sleep  with  frequent  starting  in  fright,  or  sleeplessness;  sensitive- 
ness to  light,  and  noises.  Sometimes  there  is  yomiting.  The 
transition  to  the  height  of  the  disease  is  sudden,  stormy,  and  takes 
place  with  signs  of  severe  congestion.  Consciousness  is  reduced  to 
a  dreamy  state,  and  the  patient  becomes  delirious  and  raving. 

At  first  the  disease-picture  may  present  the  characteristics  of  a 
mixed  or  angry  furious  mania  (especially  when  the  exciting  cause  is 
an  angry  affect).  If  the  mania  is  characterized  by  profound  disturb- 
ance of  consciousness  and  interruption  of  the  psychic  activities  with 
predominance  of  instinctive  movements  of  a  stormy,  impulsive  charac- 
ter, then  the  disease-picture  shows  more  the  features  of  incoherent 
delirium  and  forced  organic  movement — as  expression  of  the  intense 
psychic  and  psychomotor  cerebral  irritation,  with  violent  fluxion  and 
profound  disturbance  of  consciousness. 

The  course  of  thought  is  extremely  rapid,  confused;  at  most 
there  is  nothing  more  than  association  through  assonance  and  allitera- 
tion. The  delirium  becomes  extremely  disconnected,  and  at  the  height 
of  the  excitement  expresses  itself  only  in  disconnected  words,  syllables, 
and  cries.  The  chain  of  thought  is  constantly  interrupted,  and  with 
the  continuance  of  psychomotor  excitement  there  is  at  times  verbig- 
eration. 

The  deliria  are  mainly  anxious  and  frightful.  ,The  patients  talk 
mainly  of  the  destruction  of  the  world,  universal  destruction,  death, 
poison.  They  see  everything  around  them  tumbling,  burning,  and 
that  they  are  being  buried  in  the  ruins.  They  have  never  been  in  this 
world,  never  existed  (annihilation  of  consciousness  of  personality). 
With  this  there  may  be  also  spontaneous  episodic  ideas  of  grandeur. 
Visions  of  blood  and  fire  are  especially  frequent.  As  a  motor  reactive 
manifestation  there  are  despairing  efforts  to  escape  from  the  threat- 
ening destruction.  Such  motor  acts,  though  of  psychic  origin,  owing 
to  the  profound  disturbance  of  consciousness  and  the  accompanying 
loss  of  muscle-sense  and  motor  ideas,  have  a  peculiar  purposeless, 
uncertain,  and  impulsive  character.  Symptoms  of  irritation  in  the 
psychomotor  centers  are  soon  added:  the  patient  throws  himself 
about  without  end  or  purpose,  stamps  with  his  feet,  bores  in  the 
pillow  with  his  head,  snorts  and  blows  with  the  mouth,  blows  through 
his  nose,  breathes  spasmodically  and  with  ever-increasing  rapidity. 

To  these  psychomotor  manifestations  which  have  still  an  ap- 
parently voluntary  character,  in  the  further  course  symptoms  of  irrita- 
tion in  the  suhcortical  centers  are  added.    There  is  grinding  of  the 


550  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

teeth,  making  faces,  strabismus,  tonic  spasm  of  the  muscles  of  the- 
jaw,  spasm  of  the  nose,  jerking  movements  of  the  extremities,  reacli- 
ing  the  degree  of  general  tonic  and  clonic  spasms.  Speech  is  also 
disturbed,  stuttering,  indistinct  (due  to  ataxia,  insufficiency  of  the 
muscles,  dryness  of  the  mouth),  and  nasal  (due  to  paresis  of  the  soft 
palate). 

Tn  many  cases  reflex  excitability  undergoes  general  increase. 
The  contortions  of  the  body  are  then  in  part  due  to  this;  just  as  in 
rabies  or  in  strychnine  intoxication  mere  touching  of  the  body  may 
lead  to  general  convulsive  discharge.  Under  such  circumstances 
swallowing  is  much  interfered  with,  the  food  is  regurgitated  and  spit 
out.  "Where  reflex  excitability  is  not  intensified,  the  taking  of  food 
is  not  interfered  with  unless  there  be  temporarily  setting  of  the  jaws, 
or  the  patient  shuts  his  teeth  as  a  result  of  delusions  of  poisoning. 

The  sensibility  of  the  skin  and  the  sense-organs  in  this  stage  is 
intensified,  as  a  rule.  Sleep  is  wanting  or  limited  to  short  slum- 
ber, with  frequent  awaking  in  fright.  In  the  very  first  days  of 
the  fully  developed  disease-picture  there  are  symptoms  of  profound 
general  physical  involvement.  In  the  majority  of  cases,  in  the  very 
beginning  the  temperature  is  elevated,  or  at  least  there  is  fever 
during  the  exacerbations  of  the  malady.  The  temperature  may  vary 
between  38°  and  39°  C,  but  not  infrequently  it  attains  from  40°  to 
41°  C.  or  more.    The  ten^perature  curve  is  very  irregular. 

General  nutrition  sinks  ra]ndly,  even  when  there  is  no  fever 
and  sufficient  food  is  taken.  Within  a  very  few  days  subcutaneous 
adipose  tissue  and  turgor  vitalis  disappear.  The  lips  and  tongue  soon 
become  dry,  and  the  mucous  membrane  of  the  mouth  is  covered  with 
a  brown  coating;  the  pulse  becomes  small,  soft,  frequent  (usually 
over  100),  and  the  general  condition  adynamic,  with  signs  of  heart- 
weakness  and  tendency  to  hypostasis  in  the  lungs. 

The  patient's  face,  until  this  period  congested,  now  becomes  pale 
and  even  at  times  cyanotic.  If  the  patient  live  long  enough,  there 
are  usually  petechia,  suggillations,  and  decubitus.  Salivation  is  not 
infrequent.  Constipation  is  a  regular  symptom  in  the  early  period. 
Albumin  is  often  found  in  the  urine. ^    Constantly  during  the  course 


^The  cases  present  various  combinations  of  symptoms  in  accordance  with 
the  constitutional  peculiarities  or  the  causes.  Thus,  cases  of  stormier  course 
with  violent  symptoms  of  irritation  of  the  psychic  or  motor  spheres  (furibund 
deliria,  violent  jactitation,  grinding  of  the  teeth,  striking,  treading,  etc.),  with 
high  fever,  etc.,  are  observed,  in  contrast  with  other  cases  in  which  there  is 
early  an  adynamic  state  with  evidence  of  cerebral  pressure    (stupor,  sopor) 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       551 

of  the  disease  there  are  profound  remissions  lasting  hours  or  days 
in  which  the  delirium  disappears  and  is  even  corrected.  Conscious- 
ness clears  up,  the  temperature  is  lowered,  may  even  become  nor- 
mal, the  motor  signs  of  irritation  disappear,  and  the  remarkably 
lucid  or  only  slightly  stuporus  patient  presents  the  picture  of  simple 
exhaustion,  complaining  at  most  only  of  headache,  and  is  seemingly  on 
the  way  to  convalescence. 

It  is  hut  rare  that  this  expectation  is  fulfilled,  with  remissions 
becoming  more  and  more  perfect  and  lasting;  as  a  rule,  there  is  but 
deceptive  improvement,  to  be  followed  by  even  more  violent  exacer- 
bations. 

With  this  variation  between  congestive  exacerbations  and  remis- 
sions having  the  character  of  exhaustion  the  disease  pursues  its 
further  course,  but  the  strength  of  the  patient  is  more  and  more 
reduced  and  the  malady  takes  on  an  adynamic  character. 

Out  of  the  disease-picture  of  active  congestive  cerebral  inanition 
there  develops  with  increasing  clearness  that  of  transudative  passive 
hyperemia  of  the  central  organ. 

The  stupor  becomes  sopor;  the  motor  signs  of  irritation  become 
ataxia,  muscular  insufficiency,  and  paresis  (carphology,  uncertain 
picking  and  brushing  with  the  hands,  tremor  in  the  face  and  hands, 
difficulty  in  swallowing,  etc.);  the  stormy  deliria  become  muttering; 
the  pupils,  for  the  most  part  narrowed  until  this  time,  become  dilated 
and  slow  in  reaction;  the  conjunctiva  and  skin  become  anesthetic; 
the  cheeks  become  pale  with  cyanotic  tinge;  the  heart-sounds  become 
dull;  the  pulse  grows  increasingly  softer  and  more  frequent  (150  or 
more);  the  patient  collapses;  the  skin  is  covered  with  clammy  sweat; 
decubitus  and  pulmonary  hypostasis  develop;  the  temperature  falls 
to  the  degree  of  collapse  to  rise  again  sometimes  in  the  agony  as  high 
as  40°  C.  or  more.  Death  results  from  arrest  of  the  heart  in  pro- 
found sopor,  usually  following  upon  an  exacerbation  with  congestive 
symptoms.  The  duration  of  the  disease  is  seldom  less  than  ten  or 
more  than  twenty-one  days  up  to  the  fatal  termination.  In  cases  in 
which  life  is  saved,  several  weeks  or  months  are  required  for  conva- 
lescence, and  the  brain  does  not  pass  through  this  severe  malady 


predominating  over  symptoms  of  irritation,  in  which  the  deliria  are  almost 
wanting  or  have  a  more  dreamy,  muttering  character,  when  the  motor  dis- 
turbances are  mainly  those  of  ataxia,  muscular  insufficiency,  and  weakness, 
with  absence  of  fever  or  but  slight  elevation  of  temperature,  and  with  a  slow 
course.  Upon  this  rests  Schüle's  division  of  the  disease  into  a  meningitic  or 
maniacal,  and  an  inanition  or  melancholic  form;  but  this  author  expressly 
recognizes  mixed  forma. 


552  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

without  undergoing  a  permanent  alteration,  manifested  in  a  slight 
degree  of  mental  wealmess  and  great  emotional  excitability.  Termi- 
nation in  dementia  has  been  observed  by  some  physicians. 

Jelin  describes  the  clinical  manifestations  of  the  reactive  conditions  of 
acute  deliria  as  follows:  The  patient  begins  to  whine,  the  fliglit  of  ideas 
diminishes,  the  motor  unrest  becomes  peculiarly  slow  and  feeble,  and  he  lies 
for  weeks  at  a  time  exhausted  and  without  will.  He  must  be  waited  upon 
and  fed  like  a  child.  With  this  there  are  trophic  disturbances  (falling  of  the 
hair,  exfoliation  of  the  skin,  arrest  of  growth  of  the  nails,  scanty  improvement 
in  nutrition) ;  motor  disturbances  in  the  form  of  cataleptic  retention  of  posi- 
tions, tetanus-like  stiffness  of  the  neck;  vasomotor  disturbances  in  the  form  of 
pcniphigus-like  eruption,  especially  on  the  back  of  the  hands  and  feet,  phleg- 
mons, decubitus,  excoriations,  cyanosis,  edema  of  the  extremities,  with  cardiac 
weakness;  mental  oblivion  and  inexcitability  to  the  degree  of  stupor;  weak, 
slow  retlexes,  and  analgesia.  Gradually  there  is  termination  in  dementia, 
with  disappearance  of  the  muscular  tension  as  expression  of  the  transition  to 
severe  nutritive  disturbance  of  the  cortex  (atrophy).  In  mild  cases  i  liave 
seen  merely  states  of  profound  functional  exhaustion  lasting  weeks  or  months 
which  ended  in  recovery  (comp.  Case  70). 

It  is  very  important  to  recognize  this  pernicious  brain  disease 
early.  It  is  easily  confounded  by  inexperienced  physicians  with  mania 
or  diagnosticated  indefinitely  as  "brain  typhoid."  As  distinguishing 
it  from  mania,  we  have  the  beginning  in  severe,  though  possibly 
indefinite,  symptoms  of  central  disease;  the  profound  disturbance  of 
consciousness  which  exists  from  the  beginning;  the  great  confusion 
not  dependent  upon  flight  of  ideas ;  and  the  early  occurrence  of  symp- 
toms of  motor  irritation  which  have  no  psychic  features  and  do  not 
belong  merely  to  the  cortical  areas,  but  are  symptoms  of  direct  irrita- 
tion and  more  particularly  the  expression  of  implication  of  the  sub- 
cortical centers. 

In  the  further  course,  the  profound  implication  of  the  organism, 
fever,  and  the  remarkable  alternation  of  remissions  that  may  reach 
the  degree  of  lucidity,  with  periods  of  profound  disturbance  of  con- 
sciousness and  signs  of  psychomotor  irritation,  make  the  diagnosis 
certain. 

It  might  easily  be  confounded  with  spontaneous  meningitis  of 
the  convexity.  The  difl'erential  diagnosis  depends  upon  the  more 
frequent  occurrence  of  meningitis  in.males,  its  peracute  beginning,  the 
frequency  of  an  initial  chill,  the  early  occurrence  of  sopor,  stiffness 
of  the  neck,  the  general  hyperesthesia,  the  violent  convulsions,  and 
the  less  marked  remissions  in  its  course. 

The  prognosis  of  acute  delirium  is  rather  unfavorable.  Of  -J  5 
cases,  26  died — 15  males  out  of  22,  and  11  females  out  of  23.     This 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       553 

would  indicate  that  the  prognosis  in  women  is  more  favorable.  It 
was  especially  unfavorable  in  cases  where  the  acute  delirium  had  de- 
veloped upon  the  foundation  of  chronic  alcoholism.  The  more  acute 
and  dreamy  the  development;  the  more  profound  the  disturbance  of 
consciousness;  the  more  frequent,  early,  and  widespread  the  signs 
of  motor  irritation;  the  more  marked  the  implication  of  the  whole 
organism  and  the  more  obstinate  the  sleeplessness, — the  more  serious 
is  the  case.  Absence  of  profound  and  prolonged  remissions  is  of  bad 
omen,  as  is  lasting  avoidance  of  food.  The  fever  is  no  criterion, 
though  temperatures  that  reach  40°  C.  or  more,  and  collapse  tempera- 
tures, are  decidedly  bad  symptoms;  and  a  pulse  that  continues  ovei' 
100  is  ominous. 

In  the  stage  of  congestion  and  irritation  treatment  must  be 
directed  to  overcoming  the  hyperemia  by  means  of  ice,  lukewarm 
baths,  careful  application  of  leeches  behind  the  ears,  and  elimination 
by  the  skin  and  alimentary  tract.  Opium,  so  useful  in  acute  menin- 
gitis, is  here  without  effect.  Small  injections  of  morphine  (0.01  to 
0.015  gram)  several  times  daily  ameliorate  the  psychic  irritation  as 
well  as  the  jactitation  and  the  course  of  the  disease,  especially  in  eases 
that  are  accompanied  by  great  disturbance  of  reflex  excitability. 

The  results  obtained  by  Solivetti  by  means  of  injections  of 
ergotine  are  worthy  of  consideration, 

Solivetti  used  Bonjean's  ergotine.  He  diluted  1  gram  with.  6  grams  of 
distUled  water  and  injected  this  solution  in  three  doses  daily.  While  previ- 
ously all  his  patients  died,  with  this  treatment  he  states  that  he  never  lost 
another.  Usually  after  4  grams  on  the  fourth  day  the  danger  was  passed. 
On  the  second  day  with  diminution  of  congestion  the  deliria  disappeared,  and 
there  was  more  calm  and  subsidence  of  the  fever.  On  the  fourth  day  con- 
valescence with,  of  course,  profound  and  continued  exhaustion..  Since  Soli- 
vetti's  communication  I  have  treated  many  severe  cases  of  primary  acute 
delirium  with  similar  favorable  results.  Ergotine  (Wernich)  was  injected  sub- 
cutaneously  without  dilution  and  without  bad  results,  and  always  at  the 
moment  when  new  fluxionary  symptoms  manifested  themselves. 

Absolute  rest,  a  darkened  room,  the  most  strengthening,  but 
unirritating,  food  (eggs,  milk,  bouillon),  are  also  indicated.  If  the 
patient  enters  the  stage  of  venous  stasis  and  exhaustion,  then  wine 
and  quinine  must  be  administered;  and,  when  the  heart's  action  is 
insufficient  and  there  are  symptoms  of  collapse,  champagne,  ether, 
and,  in  case  of  necessity,  camphor  and  musk  should  be  tried. 

Case  70. — Acute  delirium. 

Mrs.  M.,  aged  37;  her  father  was  a  drunkard.  Father's  brother  was 
insane.     Patient  is  said  to  have  been  previously  healthy;   was  married  in  1863, 


5  5 J:  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

and  up  to  1S74  had  borne,  without  special  accident,  four  children.  In  her 
fourth  lying-in  period  in  187-1  she  had  an  attack  of  melancholia  without  delu- 
sions. On  July  10,  1875,  in  the  third  month  of  her  fifth  pregnancy,  she  entered 
tlie  liospital  on  account  of  the  intensification  of  tlie  melancholia  and  was  dis- 
charged recovered  September  5,  1875.  The  patient  was  delivered  without 
accident  in  Advent,  and  nursed  the  cliild  eighteen  months.  On  July  1,  1877, 
the  child  was  weaned.  On  July  3d  she  became  sad,  anxious,  disturbed,  sleep- 
less, and  had  visions  of  the  devil.  On  the  5th  twelve  leeches  were  applied. 
Immediately  there  was  stupor  and  then  violent  delirium.  AVhen  admitted  on 
the  6th  profuse  menses  (secale),  inanition-delirium  (profound  exhaustion, 
general  reduction  of  nutrition,  numerous  visual  hallucinations). 

Rapid  recovery  toward  the  middle  of  July.  "Well  thereafter.  The  death 
of  her  husband  on  February  28,  1878,  was  taken  with  much  resignation. 
March  2,  1878,  the  patient  became  sleepless,  complained  of  dizziness,  headache, 
was  restless,  at  one  time  gay  and  dancing,  at  another  in  a  painful  state.  On 
the  3d  decided  remission.  On  the  4th  she  again  manifested  alternations  of  feel- 
ing and  had  frightful  auditory  and  visual  hallucinations.  On  INlarch  5th  there 
was  violent  headache,  with  jDrofound  disturbance  of  consciousness. 

When  admitted  March  6th  she  was  in  menstruation,  with  profound  dis- 
turbance of  consciousness,  dreamy  recognition  of  familiar  places  and  persons. 
Phases  of  stupor  and  stiffness  alternate  with  others  in  which  she  sings  and 
dances  and  throws  everything  about  in  impulsive  motor  imrest.  Then  epi- 
sodically there  is  apprehensive  excitement  in  which  she  calls  to  her  dead  hus- 
band, sees  him,  reproaches  him  with  having  left  her  alone;  she  sees  the  house 
burning,  and  takes  those  around  her  for  enemies. 

The  patient  is  without  fever,  pupils  dilated.  Distinct  anemia,  reduced 
general  condition.  Up  to  the  9th  the  desultory  delirium,  the  confusion,  and 
the  disturbance  of  consciousness  excite  suspicion  of  a  serious  disease,  but 
neither  fluxion  nor  fever,  nor  sjTnptoms  of  motor  irritation  permit  a  diagnosis 
of  acute  delirium. 

On  ]\Iarch  9th,  with  the  cessation  of  the  menses,  the  scene  changes.  The 
patient  presents  violent  fluxion,  turns  about  in  forced  movements  on  her  long 
axis,  sees  herself  surroimded  with  flames  in  purgatory,  tears  her  clothing  off, 
and  tries  to  J)ut  out  the  fire.  For  hours  at  a  time,  marked  remissions  witli 
recognition  of  those  aroimd  her.  During  these  periods  of  calm  there  is  re- 
markable pathetic  speech,  theatric  posing,  becoming  at  times  ecstatic.  Con- 
tinuously sleepless.  After  a  profound  remission  on  the  morning  of  the  10th  a 
state  of  violent  excitement  with  fluxions  in  which  she  pounds  her  head  on  the 
floor,  cries,  verbigerates,  makes  faces,  and  presents  strabismus  and  nystagmus. 
Temperature,  37°  C;  pulse,  100  (ice-bag).  After  half  an  hour,  with  subsid- 
ence of  the  congestion,  the  patient  lies  exhausted  and  quiet,  with  disturbed, 
frightened  expression.  Now  and  then  making  faces.  No  hindrance  to  taking 
food.     The  excitement  is  repeated  in  the  afternoon. 

March  11th,  sleepless,  quiet,  exhausted,  consciousness  profoundly  dis- 
turbed, making  faces.     Temperature,  38.4°  C.     Tongue  dry. 

On  March  12th,  a  quiet  night  after  an  injection  of  morphine  (0.01  gram)  ; 
temperature,  39°  C.  In  the  course  of  the  day  profound  remissions  with  subsid- 
ence of  temperature  to  38°  C,  which  with  morphine  and  leeches  (on  the  13th 
and  15th,  four)  lasts  until  March  16th.  Congestive  states  of  excitement  less 
frequent  and  milder,  with  profound  remissions  interposed,  and  with  subsidence 


\         DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       555 

of  temperature  from  39°  C.  to  38°  C.  Violent  exacerbation  on  the  10th  after 
a  quiet  night.  Forced  striking  with  the  hands,  snapping  and  blowing  with  the 
mouth,  making  of  faces,  strabismus.  She  rolls  her  body  about;  temperature, 
39°  C. ;  pulse,  84,  quick,  strong.  Tongue  dry  and  cracked.  Confused  deliria 
of  hell  and  fire. 

On  the  17th,  failing,  adynamic  state.  Subsultus  tendinum,  awkward 
movements  of  the  hands,  evidently  much  disturbance  of  motor  ideas,  making 
of  faces,  accentuation  of  syllables,  verbigeration.  This  state  continues  until 
the  20th,  with  occasional  remissions,  which  now  are  nothing  more  than 
stuporous  states  of  exhaustion  (wine  and  quinine). 

On  the  20th  the  temperature  rises  to  40.5°  C,  the  pulse  to  128.  Clammy 
sweat,  cool  extremities,  general  ataxia.,  uncertain  movements  of  touch  and 
prehension.     Sometimes  still  making  of  faces,  rolling  about,  I'ising  up. 

Profound  remission  in  the  afternoon ;  she  wishes  to  see  the  children  once 
more  and  then  die.  '-'0  how  happy  I  shall  be  in  heaven  with  my  husband." 
She  wishes  to  confess  because  she  will  die  to-day.  At  noon  vomiting  of  food 
containing  three  intestinal  woi'ms.  Vomiting  again  in  the  evening.  Death 
suddenly  at  9  o'clock. 

Autopsy:  Skull-cap  of  ordinary  thickness,  very  compact,  somewhat  more 
prominent  in  the  right  parietal  region.  Inner  cerebral  membranes  present 
serous  infiltration;  the  large  veins  dilated  with  dark,  fluid  blood;  the  small 
veins  moderately  injected,  but  along  medial  border  slightly  clouded.  Brain 
swollen.  Cortical  svibstance  streaked  with  injected  vessels,  with  fine  points, 
slightly  reddened  in  places.  Brain  soft;  white  substance  quite  rich  in  blood 
and  filled  with  dilated,  injected  vessels.  Hypostatic  congestion  of  the  lungs. 
Heart  but  slightly  contracted,  containing  dark,  fluid  blood.  Heart-muscle 
pale,  relaxed.  Spleen  enlarged  one-half,  pulp  pale  brown,  soft.  Spinal  cord 
in  general,  but  especially  in  the  gray  substance,  rich  in  blood. 

Case  71.- — -Acute  delirium.  Treatment  with  ergotine.    Eecovery. 

Helene  B.,  aged  37,  single,  servant,  was  admitted  February  25,  1882,  to 
the  psychiatric  clinic  in  Gratz.  Her  father  was  a  drunkard.  She  had  rickets, 
was  of  low  mental  endowment  and  developed  slowly,  learning  to  walk  and 
speak  late.  Menses  began  at  17  with  pain.  Thereafter  they  were  regular. 
No  severe  diseases.  She  had  a  tendency  to  congestion  and  was  intolerant  of 
alcohol.  In  the  middle  of  January,  1882,  the  patient  took  a  new  place.  For  a 
long  time  she  had  felt  sick  and  nervously  weak.  Her  new  place  was  very  hard 
and  she  had  many  unpleasant  things  to  meet.  She  felt  her  strength  failing 
more  and  more. 

Since  February  18th  the  patient  had  grown  more  and  more  forgetful, 
more  confused,  and  more  awkward  in  her  work.  She  complained  of  headache 
and  left  her  wine  untouched  because  it  mounted  to  her  head.  On  the  24th  she 
was  scolded  by  her  mistress  on  account  of  her  inaptitude.  At  this  she  became 
entirely  confused,  beside  herself,  and  commenced  in  the  afternoon  to  be 
delirious.  She  was  found  at  the  fireplace  crying  and  striking  the  wall  with  her 
fists.     She  talked  about  imprisonment  and  said  the  mistress  was  innocent. 

After  passing  a  delirious  and  sleepless  night  on  the  25th,  the  patient 
began  to  shout  and  cry,  was  profoundly  disturbed  in  consciousness,  and  con- 
fused. She  was  afraid  of  those  around  her,  and  also  at  times  expressed  fear 
of  herself,  she  was  so  foolish. 


556  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Patient  is  without  fever,  not  congested,  the  skull  hydrocephalic.  No 
vegetative  findings. 

On  the  27th  and  2Sth  the  patient  remains  in  a,  state  of  profound  disturb- 
ance of  consciousness  and  delirious  confusion.  An  irritated,  angry,  appre- 
hensive state  of  feeling  predominates;  episodically  there  is  eroticism  and  a 
pathetic,  exalted  manner.  She  is  quite  occupied  with  illusional  and  hallucina- 
tory phantasms;  sleepless,  l^ie  nigiit  of  March  1st  was  passed  more  quietly 
with  2  grams  of  chloral. 

During  the  course  of  March  1st  the  pulse  rose  to  110  and  the  temperature 
to  38.5°  C.  Great  confusion,  ai>prclu'nsive  cries,  occasional  complaints  of 
frightful  noises,  and  that  the  devil  left  her  no  peace. 

March  2d,  sleepless  night,  angry,  anxious  excitement,  profound  disturb- 
ance of  consciousness,  tongue  becoming  dry.  Jactitation,  verbigeration,  boring 
the  head  in  the  pillow.  Temperature,  39°  to  39.5°  C. ;  pulse,  90  to  110.  (Dark- 
ened room,  two  leeches  behind  the  ears,  0.01  gram  of  morphine  subcutaneouslj' 
twice  daily,  ice-bags.) 

March  3d,  .sleepless  night,  great  jactitation,  forced  boring  with  the  head 
in  the  pillow,  throwing  the  arms  about,  hammering  rhytlunically  with  lier 
legs,  violent  congestion  of  the  head,  sufficient  food.  Temperature,  38.6°  to 
39°  C. ;   pulse,  110  to  135.     Two  leeches  in  the  evening. 

IMarch  4th  she  slept  a  few  hours  until  midniglit.  Tlien  there  was  jactita- 
tion, boring  in  the  pillow,  crying,  shouting,  and  "she  would  not  let  herself  be 
cut  into  bits."  Temperature,  39°  C. ;  pulse,  120.  Decubitus.  With  continu- 
ance of  the  injections  of  morphine  twice  daily,  to-day  1  gram  of  Wernich's 
ergotine  subcutaneously. 

March  5th,  sleep,  diminution  of  congestion  and  of  the  cerebral  irritation. 
Temperature,  38.5°  C.;  pulse,  96;  tongue  becomes  moist.  Still  profound  dis- 
turbance of  consciousness.  Toward  evening  some  increase  of  excitement  and 
congestion.     Another  injection  of  ergotine. 

March  6th,  slept  well.  Temperature,  38°  C.;  pulse,  96.  Traces  of  clearing 
of  consciousness. 

From  March  7th  on,  temperature,  37.2°  to  38°  C.;  pulse,  84  to  96.  All 
irritative  and  congestive  signs  have  disappeared.  The  patient  becomes  lucid, 
tries  to  comprehend  her  situation.  The  patient,  however,  is  physically  and 
mentally  greatly  exhausted,  and  shows  great  need  of  rest  and  sleep.  Her 
whole  body  feels  sore,  tired,  weak.  She  cannot  bear  the  slightest  noise,  com- 
plains of  alternating  feelings  of  heat  and  cold,  is  very  emotional,  whining,  and 
now  and  then  feels  her  mental  incapability  to  be  painful.  When  she  closes  her 
eyes  she  has  phantasms,  and  a  crowd  of  confused  and  unpleasant  ideas  come 
up.  With  rest  in  bed,  quinine,  wine,  rich  food,  lukewarm  baths,  the  patient 
recovers  mentally  and  physically.  Toward  the  end  of  March  she  can  pass  a 
few  hours  sitting  up.  This  condition  is  followed  by  cerebral  and  spinal 
asthenia,  with  pressure  in  the  head  and  spinal  irritation  lasting  several 
months,  which  passes  otf  satisfactorily  during  the  simimer. 

"^^Hien  she  was  discharged  on  April  28th  the  patient  confirmed  this  his- 
tory, especially  with  regard  to  the  strain  and  unpleasantness  she  had  suffered 
in  service.  From  February  20th  she  had  no  rest  and  no  more  real  sleep,  and 
felt  an  increasing  confusion  and  dullness  in  her  head.  After  the  scene  on 
February  24th  she  was  anxious,  frightened,  and  no  longer  knew  Avhat  she  was 
about.     Uf  ever\  thing  that  hud  taken  place  up  to  about  the  middle  of  March 


DISEASES  WITH  PREDOMINATING  PSYCJHIC  SYMPTOMS.       5.57 

the  patient  had  only  a  very  summary  memory — she  lay  in  water,  (Jratz  was  in 
flames,  she  was  in  a  railway  train,  saw  war,  Death,  the  devil,  her  neck  was 
burning,  she  heard  singing,  and  feared  she  would  be  killed. 


CHAPTER  II. 
Dementia  Paralytica  (Periencephalomeningitis  Diffusa)/ 

This  disease  may  be  defined  clinically  as  a  brain  disease,  usually 
chronic,  with  vasomotor,  psychic,  and  motor  functional  disturbances, 
of  progressive  course,  lasting,  on  an  average,  from  two  to  three  years, 
and  ending  almost  always  fatally. 

The  psychic  disturbances  consist  of  progressive  deterioration 
of  the  general  intellectual  power  to  the  most  extreme  degree  of 
apathetic  dementia.  Upon  this  foundation  there  are  changeable 
states  of  melancholia,  mania,  furor,  delusions  of  grandeur  and  the 
opposite,  of  persecution,  hypochondriacal  delusions,  stupor,  etc.  In 
general,  the  motor  disturbances  consist  of  changing,  but  progressive, 
disturbance  of  co-ordination  of  movement,  reaching  finally  complete 
loss  of  co-ordination. 

There  are  numerous  intercurrent  weaknesses  of  muscles  reach- 
ing the  degree  of  paralysis,  and  apoplectiform  and  epileptiform 
attacks. 

The  vasomotor  disturbances  consist  of  progressive  paresis  of  the 
vasomotor  nerves,  reaching  complete  paralysis.  Temporarily,  as  a 
result  of  this  vascular  paralysis,  there  are  attacks  of  dizziness,  con- 
gestion, fury,  etc. 

From  an  anatomic  standpoint  fhe  disease  is  regarded  as  chronic  men- 
ingitis (Meyer),  cerebral  atrophy  (Erlenmeyer),  general  cortical  cerebritis 
(Parchappe),  periencephalomeningitis  diffusa  chronica  (Calmeil).  The  last 
term  is  the  most  comprehensive  and  suits  best  cases  of  classic  paralysis. 
Among  the  laity  the  incorrect  term  of  "brain  softening"  is  current.  Clinically 
it  is  called  dementia  with  paralysis  (incorrectly,  for  the  motor  disturbances 
are  not  complications,  but  integral  symptoms  of  the  disease),  general  pro- 
gressive motor  ataxia  of  the  insane,  general  progressive  paralysis  of  the 
insane,  paralytic  insanity,  and  dementia  paralytica. 

Genekal  Picture  and  Couhse  of  the  Disease. 

Before  attempting  to  consider  the  symptoms  in  detail,  it  seems 
necessary  to  give  a  general  view  of  the  course  and  grouping  of  the 
symptoms  of  the  disease. 


^  Common    English    synonyms :    paralytic    dementia ;    paretic    dementia ; 
paresis;    general  paralysis;   general  paralysis  of  the  insane. — Tbanslatob. 


558  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  vasomotor  symptoms  are  the  earliest  to  appear.  Then  come 
the  psychic  and  the  motor.  The  psychic  symptoms  may  occur  simul- 
taneously with  the  motor  or  precede  them,  or  in  rare  cases  follow 
them. 

The  clianges  in  the  cortex  of  the  brain  which  induce  these 
symptoms  develop,  in  the  vast  majority  of  cases,  very  gradually,  and 
cause,  after  they  have  attained  a  certain  degree  of  intensity  and 
extent,  decided  loss  and  irritation  in  the  psychic  and  motor  spheres. 
This  developmental  period  of  the  disease  up  to  its  acme  (mania,  delu- 
sions of  grandeur,  etc.),  and  unlil  there  has  been  destruction  of 
the  faculties  necessary  for  social  and  mental  existence,  may  occupy 
years. 

Tlie  symptoms  of  this  prodromal  stage  are  at  first  equivocal,  and 
often  for  a  long  time  permit  nothing  more  than  a  general  diagnosis 
of  a  diffuse  cerebral  affection.  The  significance  of  these  may  at  first 
be  doubtful,  in  that  the  spnptoms  may  be  covered  by  those  of  severe 
cerebral  neurasthenia  (mental  exhaustion,  difficulty  of  intellection, 
rapid  mental  fatigue,  quick  paralysis  of  attention,  difficulty  of  mem- 
ory, irritable  weakness  of  the  emotions,  agrypnia,  pressure  in  the 
head,  congestions,  vertigo,  etc.). 

The  smiilarity  of  these  symptomatic  pictures  may  still  further 
be  increased,  on  the  one  hand,  by  the  occurrence  of  decided  remis- 
sions, which  may  appear  at  first,  and  during  which  the  virtual  mental 
capability,  especially  that  of  memory,  is  retained,  and,  on  the  other 
liand,  by  the  fact  that  the  neurasthenic  seldom  fails  to  present  hypo- 
chondriac depression  with  painful  self -observation  and  exaggeration 
of  his  sufferings,  even  to  the  degree  of  fearing  brain  softening,  with 
tcedium  vUcb,  thus  siinulating  the  picture  of  hypochondriac  paralysis. 

In  other  cases  the  first  symptoms  consist  of  congestion,  headache, 
A^ertigo,  or  attacks  of  ojohthalmic  migraine.  Gradually  the  situation 
is  cleared  by  distinct,  lasting,  and  progressive  deterioration  of  the 
general  psychic  personality. 

"The  patient  becomes  another  and  knows  it  not"  (Schule). 
The  most  certain  and  important  manifestation  in  this  respect  is 
clouding  of  consciousness,  a  state  of  mental  dullness,  that  at  first  is 
often  interrupted  by  temporary  clearing,  but  which  episodically  may 
extend  to  complete  loss  of  self-consciousness,  and  thus  occasion  inter- 
ruption of  the  continuity  of  mental  existence. 

In  this  progressive  mental  clouding  the  patient  is  no  longer 
conscious  of  the  numerous  disturbances  and  defects  that  happen  to 
intelligence,  memory,  and  character. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       559 

This  clouding  of  consciousness  manifests  itself  clinically  in  two 
principal  directions  (time  and  place) :  in  lack  of  orientation  in  time 
and  place — the  patient  arrives  too  early  or  too  late,  turns  night  into 
day,  gets  lost  in  well-known  streets,  etc. 

For  similar  reasons  he  commits  a  variety  of  errors  in  society: 
he  appears  in  irqperfect  toilet  in  the  drawing-room,  goes  in  his 
night-clothes  into  the  street,  smokes  in  the  theater,  keeps  his  hat  on 
in  church,  etc. 

With  this  dulling  of  the  energy  of  consciousness  there  are  early 
associated  signs  of  weakness  of  attention,  judgment,  and  memory, 
with  consequent  nuinerous  lapses.  Weakened  power  of  attention 
causes  defect  and  incorrectness  of  apperception,  and  weakness  of 
memory-pictures  causes  mistaking  of  persons  and  situations;  weak- 
ened critical  power,  reflexion,  and  memory  lead  to  errors  of  memory — 
mistaking  of  that  which  has  been  dreamed,  read,  or  thought  for  actual 
experiences,  to  incorrect  localization  in  past  time.  The  power  of  the 
diseased  brain  to  retain  new  impressions  grows  more  and  more  feeble — 
the  most  recent  events  disappear  immediately;  a  visit,  a  repast,  or  a 
business  matter  is  immediately  forgotten ;  the  patient  relates,  for 
example,  the  same  story  several  times  in  one  evening. 

In  time  not  only  single  facts  are  lost,  but  whole  periods  of  the 
recent  past  (forgetting  being  engaged  to  be  married,  or  a  young  hus- 
band forgetting  he  is  a  father,  etc.).  Quite  early  the  signs  of  loss 
of  ethic  and  esthetic  powers  are  evident:  dullness  of  feeling  for 
occupation,  family,  and  for  those  mental  interests,  art,  science,  etc., 
that  were  formerly  highly  valued,  with  preference  for  gross  sensual 
pleasures,  eating,  drinking,  sleeping — doubly  significant  if  the  pa- 
tient were  formerly  a  man  of  fine  feeling,  preferring  exclusively 
intellectual  enjoyment.  In  the  further  course  there  may  be  the 
grossest  disregard  of  good  morals,  law,  the  duties  of  profession,  family, 
and  social  position.  The  patient,  already  deteriorated  in  his  higher 
mental  faculties,  does  not  remark  how  he  seriously  compromises  him- 
self, and  always  reacts  coarsely  and  even  brutally  when  relatives, 
friends,  or  superiors  take  him  to  task  for  his  conduct. 

In  many  patients  the  great  emotional  change  manifests  itself 
not  merely  in  signs  of  loss,  but  in  those  of  increased  impressionabil- 
ity; for  example,  in  silly  emotionality  or  in  extreme  irritability, 
varying  with  the  cause  of  the  emotion.  With  the  increasing  mental 
cloudiness;  with  the  ethic  and  intellectual  insufficiency,  forgetful- 
ness,  distraction,  laziness,  the  feebleness  of  the  will,  the  weakness 
of  esthetic  and  moral  judgment ;  with  the  neglect,  more  and  more  pro- 
nounced, of  the  most  important  duties  of  profession  and  family ;  with 


5fi0  SPECIAL  TATIIOLOGY  AND  THERAPY  OF  INSANITY. 

the  eventual  apparition  of  tendency  to  debauches  and  prodigality, — the 
social  life  becomes  constantly  more  precarious.  It  is  higlily  indicative 
of  the  poAver  of  judgment  of  the  laity  to  note  how  falsely  and  opti- 
mistically the  activity  of  such  a  patient  is  regarded,  and  how  long  he 
is  allowed  to  remain  in  a  position  that  is  detrimental  to  himself  and 
liis  subordinates. 

Thus  it  hai>pons  that  high  military  officers  retain  command  in  spite  of 
the  grossest  a<;ts  and  neglect,  in  spite  of  senseless  and  often  barbarous  treat- 
nxent  of  their  soldiers,  untU  finally  a  maniacal  paralytic  state  of  excitement 
brings  deliverance.  Thus  it  happens  that  in  bureaucratic  life  the  valued  of- 
ficial that  enters  the  asylum  to-day  was  at  his  desk  yesterday,  though  for 
months  he  had  come  to  the  office  irregularly,  was  behind  in  his  work,  forgot  to 
finish  it,  fell  asleep  in  the  midst  of  his  work,  could  not  find  important  papers 
for  weeks,  which  were  accidentally  found  by  the  porter  in  the  waste-basket. 

A  merchant  becomes  bankrupt.  He  has  been  negligent  in  his  bookkeep- 
ing for  a  long  time:  repeatedly  has  he  left  the  key  in  the  drawer  of  the  cash 
box,  misplaced  letters,  and  lost  valuable  papers.  In  his  books  are  found,  for 
many  months  back,  errors  of  date  and  figures,  letters  and  words  left  out, 
blots  and  alterations  of  the  handwriting,  etc. 

Along  with  these  diffuse  and  psychic  symptoms,  there  are  not 
infrequently  early  focal  sj'mptoms  in  the  sense  of  temporary  aphasia 
that  is  usually  amnesic,  less  frequently  ataxic,  and  coarse  awkward- 
ness of  acquired  movements,  due  to  the  loss  of  motor  notions,  which 
strike  the  patient  hims6lf.  Possibly  occasional  awkwardness  of  move- 
ment of  the  tongue,  hesitation  in  speech,  and  incapability  of  re- 
])eating  perfectly  sentences  that  have  been  heard  depend  upon  sim- 
ilar conditions.  Among  special  somatic  symptoms  of  the  prodromal 
stage  may  be  mentioned:  myosis,  inequality  of  the  pupils,  tabetic 
symptoms,  inequality  and  variability  in  the  innervation  of  the  two 
halves  of  the  face,  fibrillary  twitchings  of  the  muscles  of  the  tongue, 
occasional  tremor  of  the  extremities,  paralgic  sensations,  slow  pulse, 
congestions,  intolerance  of  alcohol  and  heat,  headache,  pressure  in 
the  head,  vertigo,  occasional  attacks  of  fainting,  or  even  apoplectiform 
attacks  followed  by  several  hours  of  mental  confusion,  and  disturb- 
ance of  speech — symptoms  which  disappear  without  leaving  any  signs 
of  paralysis. 

Early  and  important  disturbances  are  noticed  in  the  mimicry, 
speech,  and  writing.  The  facial  expression  often  becomes  veiled 
and  fatuous.  The  voice  becomes  rough  and  monotonous  and  less 
capable  of  modulation.  In  reading,  expression  is  lacking  and  marks 
of  punctuation  are  not  observed.  The  patient  reads  incorrectly,  omits 
or  substitutes  words  which  he  does  not  see.  The  speech  is  less  fluent, 
and  hesitating  oil  account  of  the  reduction  of  the  promptness  of 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       561 

association  of  the  motor  functions  in  their  relation  to  siglit  and  hear- 
ing in  forming  the  word-pictures.  Tlie  character  of  the  handwriting 
becomes  changed;  frequently  the  letters  are  smaller,  rarely  larger,  and 
at  the  same  time  rather  angular.  It  appears,  as  an  analogue  to  the 
hesitating  speech,  as  if  not  written  by  the  same  person.  Disturbed 
muscle-sense,  muscle-weakness,  and  ataxia  manifest  themselves  in  the 
incorrect  use  of  the  fine  and  heavy  lines  of  writing,  and  the  writing  is 
out  of  line,  irregxüar  in  size  of  letters,  with  angular  deviations  from 
the  line;  also  there  may  be  addition  or  omission  of  syllables  and 
words,  or  reduplication- and  confusion  to  the  extent  of  paragraphia. 

Important  prodromes  are  attacks  of  acquired  migraine;  such 
non-hereditary  attacks  occurring  late  in  life  are  almost  certainly 
precursors  or  accompanying  symptoms  of  organic  brain  disease, 
especially  general  paralysis.  As  a  rule,  such  symptomatic  attacks 
occur  in  the  form  of  ophthalmic  migraine. 

Of  great  significance  are  attacks  of  Jacksonian  sensory  epilepsy. 
They  consist  of  paresthesias  (formication  and  numbness),  which  begin 
in  half  the  face  and  tongue,  spreading  to  the  upper  and  lower  extremi- 
ties, accompanied  by  a  momentary  or  prolonged  weakness  of  the  motor 
function  of  the  affected  part. 

Such  attacks  may  be  associated  with  migraine  or  aphasia,  and 
are,  indeed,  the  clinical  expression  of  a  vasomotor  spasm  in  the  cor- 
responding motor  and  sensory  cortical  areas. 

In  rare  cases  dementia  paralytica  develops  to  its  height,  not  out 
of  such  a  prodromal  stage  of  motor  and  vasomotor  disturbances  with 
psychic  defect,  but  out  of  tabes  dorsalis  ("  ascending  form  of  paraly- 
sis ") ;  or  it  may  develop  in  the  course  of  mental  disease  that  has  long 
been  present  ("  secondary  paralysis  ") ;  or  it  may  arise  after  an  ordi- 
nary psychoneurosis  which  terminated  in  recovery  or  recovery  with 
defect  (with  signs  of  remaining  psychic  weakness).  In  the  first 
instance  the  paralysis  seems  to  be  merely  a  complication  of  the  psy- 
chosis, just  as  if  it  had  developed  in  a  healthy  individual.  In  the 
latter  case  the  question  arises  whether  the  preceding  psychoneurosis 
were  not  the  first  act  (Schule),  the  prodromal  stage,  of  the  paralytic 
disease. 

These  facts  render  many  cases  of  the  psychoses  more  difficult  of 
diagnosis,  since  it  must  be  remembered  that  in  their  further  course 
the  picture  of  dementia  paralytica  may  develop  (Schule). 

The  termination  of  the  prodromal  stage  is  marked  not  infre- 
quently by  an  apoplectiform  or  epileptiform  seizure. 

The  further  development  of  the  mental  symptoms  may  at  the 
height  of  the  disease  take  one  of  three  courses :— - 


562  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

1.  Out  of  the  proclroinal  stage  described  there  may  develop 
maniacal  exaltation,  which,  constantly  intensified  by  external  and 
inierual  causes,  becomes  associated  with  delusions  of  grandeur  and 
quickly  reaches  the  intensity  of  furious  mania. 

The  mania  may  increase  still  further  to  the  intensity  of  acute 
delirium,  or,  if  the  patient  be  brought  in  the  meantime  under  the 
favorable  hygienic  surroundings  of  an  asylum,  the  mania  may  subside 
to  the  level  of  maniacal  exaltation  with  delusions  of  grandeur.  This 
state  of  excitement  gives  place  to  a  progressive  dementia,  during  the 
course  of  which  relajjses  of  maniacal  excitement  and  grand  delusion* 
may  reappear. 

In  other  cases,  owing  to  the  occurrence  of  a  decided  remission 
lasting  months  or  years,  a  stationary  state  may  follow  upon  the 
maniacal  excitement  with  delusions  of  grandeur.  But  sooner  or  later 
the  maniacal  excitement  with  grand  delusions  again  conies  on,  and 
the  termination  is  then  the  same  as  in  the  first  instance  (so-called 
classic  paralysis). 

2.  Out  of  the  prodromal  stage  there  may  develop  a  h3'pochon- 
driac  or  melancholic  disease-picture  that  is  overshadowed  more  and 
more  by  dementia,  or  that  apparently  passes  away  with  the  occur- 
rence of  a 'remission.  After  a  longer  or  shorter  pause  the  hypochon- 
driac or  classic  picture  of  paralysis  manifests  itself  again  (melan- 
cholic form  of  paralysis). 

In  accordance  with  the  fact  that  melancholic  and  megalomani- 
acal  delusions  may  present  themselves  alternately,  a  circular  form  of 
paralysis  has  been  disting-uished. 

3.  Out  of  the  prodromal  stage  a  primary  progressive  dementia 
may  develop.  In  these  cases  there  is  neither  mania  nor  delirium  of 
grandeur,  but  there  may  be  remissions  or  intercurrent  attacks  of 
furor  (simple  demented  form  of  paralysis). 

These  varieties  of  the  disease-picture  from  the  psychic  point  of 
vicAv  may  be  accounted  for  through  the  varied  anatomic  conditions. 

The  demented  forms  without  psychic  excitement  depend  mainly 
upon  simple  primary  atrophic  changes;  classic  paralysis  with  mani- 
acal excitement  and  grand  delusions  is  to  be  attributed  in  the  main  to 
inflammatory  processes. 

The  essential  thing  in  this  disease-picture  is  the  progressive  loss 
of  the  psychic  and  psychomotor  functions  (dementia)  running  parallel 
with  the  progressive  anatomic  processes.  The  progressive  loss  of 
memory  stretches  backward  until  early  impressions  are  impaired  and 
the  patient  lives  only  in  the  present,  mistaking  persons  and  objects, 
with  temporary  mental  blindness  to  ocular  and  auditory  stimuli. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       563 

Psj^chic  associations  become  weakened  to  the  degree  that  real  and 
imaginary  occurrences  cannot  be  distinguished. 

The  great  loss  of  concepts  and  fixed  associations  brings  about 
a  great  reduction  of  the  mental  sphere.  A  pronounced  cloudiness  oC 
consciousness  and  actual  mental  torpor  come  over  the  patient,  to 
whom  the  relation  of  time  and  place,  of  forms  and  customs,  is  lost. 

The  motor  control  becomes  more  and  more  deficient,  and  thereby 
results  increasing  inability  to  carry  out  co-ordinate  movements  even 
in  the  simplest  acts. 

With  the  changeable  psychic  course  there  are  many  prominent 
disturbances  of  a  vasomotor  and  motor  kind.  Owing  to  transitory 
vascular  paralysis  in  the  domain  of  the  cervical  sympathetic,  there 
are  now  and  then  attacks  of  congestion,  vertigo,  fainting,  and  apo- 
plectiform seizures;  speech  becomes  hesitating,  slow,  indistinct;  the 
movements  of  the  hands  become  uncertain,  aM'kward  ;  the  gait  be- 
comes unsteady,  staggering,  dragging.  As  a  result  of  apoplectiform 
or  epileptiform  seizures  the  patient  may  lean  to  one  side.  The  face 
becomes  relaxed,  expressionless;  certain  branches  of  the  facial  be- 
come paretic.  There  is  tremor  of  the  tongue,  fingers,  and  lips;  the 
pupils  are  unequal — at  one  time  dilated,  at  another  contracted. 

All  these  motor  disturbances  manifest  great  variations  of  in- 
tensity and  extent.  At  times  they  are  scarcely  noticeable,  at  others 
very  marked,  especially  after  paralytic  seizures;  and  in  general  they 
are  progressive. 

The  final  stage  is  the  same  in  all  cases,  no  matter  what  may  have 
been  the  peculiarities  of  other  periods  of  the  disease. 

The  patients  have  become  apathetically  demented;  they  have 
no  consciousness  of  time  and  place ;  their  speech  is  merely  an  incom- 
prehensible murmuring  of  syllables,  the  result  of  amnesic  aphasia 
and  complete  paralysis  of  co-ordination;  walking  becomes  progress- 
ively more  difficult  and  finally  impossible,  though  gross  muscular 
power  is  retained.  The  hands  become  useless  owing  to  ataxia  and 
loss  of  motor  ideas,  so  that  the  patients  must  be  fed  like  little  chil- 
dren. The  patients  become  unclean,  owing  to  disturbance  of  con- 
sciousness and  insufficiency  of  the  sphincters.  That  the  vascular 
paralysis  has  reached  its  height  is  shown  in  the  livid,  cold,  edematous 
extremities,  the  monocrotic  sIoav  pulse,  and  the  abnormal  low  tem- 
perature (due  to  increased  dissipation  of  heat). 

Now  and  then  there  are  still  unilateral  or  bilateral  congestive 
attacks  in  the  domain  of  the  cervical  sympathetic,  with  temporary 
excitement,  jactitation,  verbigeration,  sleeplessness;  or  there  may  be 
also  apoplectiform  and  epileptiform  seizures. 


564  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

At  this  stage  there  is  almost  always  spasmodic  or  continued 
grinding  ot  the  teeth.  Trophic  disturbances  now  appear.  The 
patient,  weil  nourished  up  to  this  time,  in  spite  of  large  quantities  of 
nourishment,  grows  thin;  the  ribs  become  fragile;  lieniatoma  of  the 
ears,  decubitus,  hypostatic  pneumonia,  cystitis,  occur;  and  the  pa- 
tient dies  of  decubitus,  which  may  even  open  the  vertebral  canal;  or 
of  pyemia,  pneumonia,  cystitis,  pyelonephritis,  bulbar  paralysis  of 
deglutition,  suffocation  due  to  food  impacted  in  the  tliroat,  or  in  an 
cpileptifonn  or  apoplectiform  seizure. 

The  autopsy  in  casos  of  classic  paralysis  reveals  the  evidence  of  olironio 
difTnse  disease  of  the  soft  membranes  and  the  cerebral  substance,  witli  wliich 
there  are  certain  clianges  in  the  spinal  cord.  The  extent  of  the  chronic  inllam- 
matory  changes  in  the  pia  and  cortex  corresponds  with  the  distribution  of  (he 
larotids  (frontal  lobes  and  neighboring  areas),  and  but  rarely  extends  to  the 
areas  supplied  by  the  vertebral  arteries. 

Thus  the  process  is  essentially  a  periencephalomeningitis  diffusa  clu'onica 
of  the  forebrain.  In  one  case  the  signs  of  meningitis  predominate  (cloudiness 
and  thickening  of  the  pia,  most  intense  along  tlie  course  of  the  large  vessels)  ; 
in  another  atrophy  of  the  cortex  is  more  prominent  (narrowing  of  the  convo- 
lutions ■with  depression,  and  gaping  of  the  sulci)  ;  and  the  circumstance  that 
the  intensity  of  these  processes  is  not  always  proportional  in  the  same  regions, 
shows  that  they  are  not  directly  interdependent. 

As  cotuplications  and  resulting  changes  we  find  pachymeningitis  haemor- 
rhagica,  not  connected  with  the  territory  of  chronic  leptomeningitis;  atrophy 
and  sclerosis  of  the  white  substance  of  the  hemispheres;  chronic  ependymitis 
of  the  ventricles,  with  formation  of  granulations;  hydrocephalus,  e  vacuo 
externus  and  internus;  and  sometimes  also  gray  degeneration  of  the  optic  and 
olfactory  nerves. 

As  terminal  conditions  and  arising  during  the  agony  we  find  edema  of  tlic 
pia  and  the  brain. 

The  microscopic  findings  in  the  ganglion-cells  in  the  early  stages  and 
when  the  disease  has  manifested  a  rapid  course  consist  of  cloudy  swelling  and 
puffing  of  the  nuclei;  at  a  later  stage  of  clearing  up  of  the  nuclei,  and  oc- 
casionally of  vacuolation;  partial  fatty  and  pigmentary  degeneration  in  some 
places;  and  finally  of  destruction  of  the  nucleus  and  disappearance  of  the  cell- 
body,  either  as  a  result  of  pareneliymatous  disease  or  as  a  result  of  atropliy 
due  to  pressure. 

The  changes  in  the  nerve-fibers  are  disappearance  of  the  medullary 
sheath  and  later  of  the  axis-cylinder,  with  the  formation  of  amylaceous 
bodies;  this  change  takes  place  especially  early  in  the  medullated  radiating 
and  longitudinal  fibers,  which  serve  largely  the  purpose  of  association 
(Tuczek). 

In  the  arterioles  and  capillaries  there  is  very  early  dilatation  and  great 
proliferation  of  their  nuclei.  The  walls  of  the  vessels  undergo  thickening  and 
colloid  or  hyaline  degeneration.  Not  infrequently  in  some  localities  there  is 
new  formation  of  vessels  with  anastomoses  due  to  development  of  spider  cells. 
Terminal  findings  are  atrophy  and  obliteration  of  the  vessels  as  the  result  of 
eclerotic  proliferation  about  tüem,  as  well  as  compression  by  extravasations, 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       5G5 

as  a  result  of  wliich  the  nuclei  of  tlie  vessels  may  undergo  fatty  or  pig-in(;iitary 
degeneration. 

The  lymph-spaces  (intra-  and  peri-  vascvilar)  dilate  early  and  are  filled 
with  transudations  from  the  vessels  (leucocytes,  scattered  red  blood-corpuscles, 
colloid  masses),  by  small  hemorrhages  (pigment-nuclei),  as  well  as  by  masses 
of  small  cells  due  to  the  proliferation  of  the  nuclei  of  the  endothelial  ad- 
ventitia  (Binswanger).  Not  infrequently  we  find  cystoid  degeneration  due  to 
constriction  of  lymph-spaces. 

As  a  result  of  all  these  processes  the  vessels  and  parenchyma  undergo 
compression,  and  with  the  progress  of  the  disturbance  of  the  lymph  circula- 
tion the  way  is  prepared  for  a  condition  of  stasis. 

The  glia  shows  proliferation  of  the  intercellular  substance;  it  loses  its 
finely  granular  transparent  appearance,  becomes  fibrillary  (sclerotic),  and 
presents  enormous  increase  of  spider  cells. 

The  enormous  proliferation  of  glia  nuclei  (Mendel)  is  denied  by  Bins- 
wanger. 

The  changes  in  the  spinal  cord  almost  always  found  were  first  carefully 
studied  by  Westphal. 

Besides  pachymeningitis  interna  that  is  not  infrequent,  and  chronic  in- 
flammatory changes  in  the  pia,  we  have  here  in  the  main  to  deal  with  two 
processes: — 

(a)  Gray  degeneration  of  the  posterior  columns  throughout  their  length, 
which,  is  always  most  marked  in  the  columns  of  Goll,  but  which  may  be  lim- 
ited to  the  cervical  portion  of  them. 

(h)  A  chronic  myelitis  of  the  posterior  portions  of  the  lateral  columns: 
that  is,  a  proliferative  process  of  the  interstitial  connective  tissue  with  forma- 
tion of  nuclei,  but  without  atrophy  of  the  nerve-fibers. 

This  last  process  is  probably  a  secondary  affection  of  the  spinal  cord 
(descending  degeneration)  resulting  from  intense  disease  of  the  motor  cortical 
areas,  which  are  the  trophic  centers  for  these  conducting  paths. 

Special  Symptomatology. 

1,  Psychic  Symptoms. — The  fundamental  features  of  the  whole 
psychic  disease-picture  consist  of  symptoms  of  psychic  wealmess, 
which  is  shown  especially  in  the  superficial  character  of  the  emotions ; 
the  lack  of  energy;  the  enfeehlement  of  logic,  of  critical  power,  and 
of  memory;  and  in  general  by  the  weakness  of  the  intellectual  and 
moral  faculties,  and  the  profound  disturbance  of  intelligence. 

These  defects  lend  to  the  psychic  disease-pictures  that  present 
themselves  in  the  course  of  dementia  paralytica  special  features  which 
easily  permit  their  differentiation  from  conditions  not  dependent 
upon  mental  weakness.  Under  certain  circumstances  these  peculiar 
signs  may  indicate  to  the  expert  their  special  origin  (dementia 
paralytica),  even  when  the  motor  disturbances  are  temporarily  absent. 

The  maniacal  states  of  paralysis  may  present  themselves  in  all 
degrees,  from  the  excitement  of  simple  maniacal  exaltation  to  the 
extreme  of  furious  mania. 


566  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  features  which  immediately  distinguish  the  maniacal  exalta- 
tion of  paralysis  from  that  of  another  kind,  aside  from  the  suspicious 
jirodromal  stage  and  the  presence  of  motor  (myosis  is  frequent 
and  important)  and  vasomotor  distufl)ances,  are  the  excessive 
feeling  of  well-being,  reaching  the  degree  of  desultory  anticipated 
delusions  of  grandeur;  the  impulse  to  buy  and  speculate  with  sense- 
lessness; the  undertakings  and  projects  (purchase  of  enormous  (iiiaii- 
tities  of  articles);  and  the  tendency  to  alcoholic,  and  especially 
sexual,  excesses.  The  great  disturbance  of  intelligence  in  these 
seemingly  lucid  patients  is  betrayed  in  remarkable  lasciviousness  and 
thoughtlessness  in  the  satisfaction  of  sexual  impulses;  and  no  less 
in  the  ethic  indifference  of  such  patients  when  their  attention  is 
called  to  their  conduct.  With  this  there  are  notable  disturbances  of 
consciousness  and  lapses  of  memory,  as  a  result  of  which  they  forget 
names  and  facts,  get  lost  in  well-known  streets,  run  into  houses 
in  mistake  for  their  own,  lose  their  money  while  on  their  sense- 
less excursions,  and  forget  their  baggage  or  umbrellas;  and,  finally 
deprived  of  everything  and  bewildered,  they  are  possibly  brought 
home  by  the  officers  of  the  law.  Not  infrequently  this  state  of 
excitement  is  accompanied  by  kleptomania,  and  the  idiotic  taking  of 
things  and  denial  of  the  theft  are  no  less  indicative  of  the  distraction, 
disturbance  of  consciousness,  and  Aveakness  of  memory  of  such 
patients. 

As  a  rule,  others  now  begin  to  recognize  the  abnormal  state  of 
the  patient.  Unfortunately  the  gravity  of  the  disturbance  is  not 
yet  appreciated,  and  an  attempt  is  made  by  travel,  water-cures,  and 
amusement  to  quiet  the  nerves  which  are  supposed  to  be  merely  ex- 
cited; and  in  this  way  the  patient  has  time  to  waste  his  money  .in 
senseless  acts,  purchases,  and  other  speculations;  to  prepare  the 
financial  ruin  of  his  family;  and  by  continued  cerebral  excitement 
and  excesses  destroy  the  last  possibility  of  recovery. 

The  attacks  of  furious  mania  in  the  paralytic  may  arise  out  of 
attacks  of  maniacal  excitement  as  a  result  of  the  summation  of 
external  and  internal  stimuli.  As  a  rule,  however,  they  occur  sud- 
denly, without  cause,  and  quickly  reach  their  acme,  to  subside  again 
quite  as  suddenly.  They  may  occur  repeatedly  during  the  course  of 
the  disease,  and  even  in  the  stage  of  final  dementia.  They  last  from 
a  few  days  to  a  few  weeks,  are  often  begun  and  accompanied  by 
vascular  paralysis,  and  then  may  be  accompanied  by  fever  and 
symptoms  of  irritation  (grinding  of  the  teeth).  They  are  probably 
the  expression  of  congestive  processes  affecting  the  pia  and  cerebral 
cortex. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       507 

The  mania  of  the  paralytic,  in  consonance  with  the  profound 
idiopathic  nature  of  this  complication  and  the  great  disturbance  of 
consciousness,  is  usually  extremely  violent.  Eaving,  crying,  blind 
destructiveness,  and  smearing  are  very  common  symptoms.  With 
this  there  are  great  confusion  and  disturbance  of  consciousness,  and 
usually  also  salivation. 

The  melancholic  states  in  the  paralytic  have  the  features  of  a 
severe  organic  disturbance,  in  that  they  occur  as  stupid  melancholia, 
or  as  agitated  melancholia  with  violent  fear  reaching  the  degree  of 
panphobia,  and  are  early  complicated  by  signs  of  vascular  paralysis 
and  motor  disturbances.  The  profound  disturbance  of  consciousness; 
the  purely  primordial  character  of  the  deliria,  with  nihilistic  and 
frequently  also  hypochondriac  content;  the  early  occurrence  of 
signs  of  mental  weakness;  the  absence  of  profound  affects,  aside 
from  possible  organically  conditioned  fear  and  panphobia;  the  de- 
mented reaction  to  these  in  the  form  of  childish  weeping  and  com- 
plaining; the  occasional  occurrence  of  ambitious  delusions  in  the 
midst  of  the  melancholic  nihilistic  ideas — lend  to  these  conditions 
peculiar  features.  In  just  these  cases,  motor  disturbances  (especially 
myosis,  inequality  of  joujoils,  fibrillary  twitching  of  the  face  and 
tongue,  paresis,  and  grinding  of  the  teeth)  and  vasomotor  troubles 
(vascular  paralysis  in  the  domain  of  the  cervical  sympathetic)  ordi- 
narily come  on  early  in  the  history;  so  that  the  diagnosis  in  general 
is  not  difficult. 

The  temperature  may  also  be  of  importance  in  differentiating 
the  melancholic  and  maniacal  states  of  the  paralytic  from  ordinary 
simple  melancholia  and  mania.  Eeinhard  has  shown  that  tempera- 
ture of  the  head  higher  than  that  taken  in  the  axilla,  extraordinarily 
wide  daily  variations  of  body-temperature,  and  occasional  appearance 
of  slight  general  rise  of  temperature  without  an}^  demonstrable  cause 
point  to  general  paralysis. 

Delusions  of  grandeur  are  extremely  frequent  in  the  course  of 
paralysis.  However,  they  are  not  primary  nor  essential  nor  specific, 
as  is  very  commonly  believed.  The  manner  in  which  they  are  ex- 
pressed lipon  the  basis  of  psychic  weakness  is  of  diagnostic  importance, 
and  not  infrequently  this  alone  indicates  the  paralytic  basis. 

(a)  The  grand  delusions  of  the  paralytic  are  monstrous,  fan- 
tastic, far  surpassing  any  possibilit}-,  and  extend  be3^ond  the  limits  of 
time  and  space.  The  critical  power  of  the  patient  is  so  reduced  that 
every  thought  becomes  a  wish,  and  every  wish  immediately  actuality; 
and  his  fancy  is  unbridled  in  the  calling  up  of  ideas  of  power  and 


5G8  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

greatness — ideas  which  in  form  and  import  are  in  pitiable  and  suly 
contrast  with  their  details. 

Thus,  one  day  a  patient  announced  that  last  night  he  had  become  the 
Almighty  and  he  \vo\ild  now  have  blue  liaii-.  In  order  to  get  to  Heaven  lie 
would  build  a  cable  roaJ.  In  general  these  patients  live  in  monstrous  ideas 
of  power  and  wealth;  they  are  Napoleon,  Ctesar,  and  iJismarclc,  and  at  the 
same  time  God  and  the  superior  God;  every  tiling  around  them  is  gold  or  be- 
comes gold — even  their  excretions.  One  patient  declared  that  he  had  made 
streets  in  all  directions  over  the  earth,  and  at  the  starting-point  of  all  these 
streets  he  lived  in  a  diamond  palace  and  ruled  the  world.  In  order  to  take  a 
walk  occasionally  on  the  moon,  another  elongated  his  arm  till  it  touched  the 
moon,  and  he  then  reached  the  moon  by  this  path  in  a  wheelbarrow. 

(h)  Owing  to  his  mental  weakness,  the  patient  is  unable  to  reason 
about  or  co-ordinate  his  delusions,  and  he  does  not  notice  the  want  of 
logic  and  contradiction  in  his  delusional  ideas. 

(c)  He  lives  in  his  delusional  possessions  and  power  without 
anything  like  real  volition  to  act  in  accordance  with  his  false  ideas; 
and  even  if  he  rises  to  this  point,  owing  to  his  weakness  of  memory, 
disturbance  of  consciousness,  and  absence  of  critical  power,  a  puerile 
pretext  is  sufficient  to  turn  his  attention  in  another  direction.  On 
the  other  hand,  owing  to  lack  of  critical  power,  a  lively  thought  im- 
mediately becomes  for  the  patient  actuality;  and  it  is  not  difficult  to 
create  in  the  credulous  patient  the  most  nonsensical  false  ideas. 

(d)  An  infrequent,  but  very  important,  diagnostic  symptom,  be- 
cause it  occurs  only  in  paralytic  and  senile  dementia,  is  the  alterna- 
tion of  primordial  delusions  of  grandeur  with  those  of  micromania. 

In  this  case  again  the  extravagance  of  the  delusional  ideas  is 
manifest;  as,  for  example,  that  the  patient  is  a  dwarf  scarcely  an 
inch  high;  or  that  he  has  died  several  times,  etc. 

The  content  of  the  delusions  of  grandeur  depends  entirely  upon 
the  education  and  social  position  of  the  patient.  Sometimes  traces  of 
the  delusions  may  be  foimd  in  the  latest  stage  of  dementia. 

In  women  delusions  of  grandeur  are  less  prominent  and  more 
modest.  They  are  rather  the  elaboration  of  everyday  circumstances 
of  life.  The  patients  have  many  beautiful  silk  dresses,  numerous 
stockings;  very  often  the  false  ideas  have  a  sexual  coloring — they 
have  given  birth  to  the  most  beautiful  children  or  they  give  birth 
to  twins  every  day,  etc. 

Hypochondriac  Velirnim. — The  hypochondriac  delusions  of  para- 
lytics also  present  peculiarities  which  make  it  possible  to  differentiate 
them  from  those  of  ordinary  hypochondria.  In  these  cases  the  ele- 
ment of  impossibility  and  absurdity  is  not  wanting  as  a  necessary 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       5C9 

result  of  the  profound  disturbance  of  consciousness;  intelligence,  and 
critical  power.  While  the  ordinary  hypochondriac  entertains  false 
ideas  that  are  still  within  the  range  of  possibility,  the  delusions  of  the 
paralytic  are  marked  by  impossibility. 

The  patients  seem  to  themselves  smaller  or  larger,  or  three-cornered; 
their  heads  or  their  tongues  have  been  removed;  tlicir  organs  dried  up  or  the 
passages  of  the  body  stopped  up;  they  cannot  eat.  One  of  my  patients  was 
astounded  about  his  great  length,  for  formerly  he  had  been  merely  a  point. 
He  complained  that  his  brain  was  now  only  an  air-bladder  and  had  fallen  into 
his  abdomen.  His  abdomen  was  filled  with  electricity,  and  his  brain  had  be- 
come the  sun  (reminiscence  of  the  solar  plexus),  and  with  this  brain-sun  he 
had  set  the  whole  world  on  fire.  Another  patient  constantly  complained  that 
his  larynx  had  slipped  into  his  stomach;  that  all  his  intestines  bad  passed 
away  with  an  enema;  his  tongue  was  hanging  merely  by  a  thread;  his  verte- 
brae were  detached,  and  his  blood  was  poisoned  by  prussic  acid,  etc. 

These  delusions  are,  in  part,  primordial;  in  part,  demented  and 
false  interpretations  of  actual  sensations  (anesthesias,  etc.). 

Primary  progressive  dementia,  of  late  decidedly  the  most  fre- 
quent form  of  paralysis,  also  presents  features  which  distinguish  it 
from  ordinary  dementia.  The  sense  of  self  and  apperception  of  the 
external  world  are  not  characterized  by  the  indifference  of  ordinary 
dementia,  but  present  an  optimistic  coloring;  there  is  early  profound 
disturbance  of  intelligence  with  reference  to  time,  space,  and  per- 
sonality; the  patients  lead  a  truly  clouded  existence.  With  this,  cer- 
tain outer  forms  of  conventionalit}^,  politeness,  or  soldierly  bearing 
are  often  long  retained  and  mask  outwardly  the  defect. 

The  disturbance  of  memory  is  also  peculiar:  while  the  events 
of  time  long  past  may  still  be  reproduced  correctly,  those  of  late 
events  are  instantly  forgotten  (the  hour  for  meals,  visits,  etc.). 

The  Remissions  in  tlie  course  of  the  disease  may  occur  at  any 
time,  and  last  weeks  or  months  or  even  years.  Especially  in  the 
initial  stages  of  the  disease  they  are  often  very  marked,  and  may  be 
confounded  with  intermissions  or  recovery.  However,  there  are  al- 
ways signs  of  mental  weakness,  defective  thought,  susceptibility  to 
influence,  great  irritability,  and  all  sorts  of  anomalies  of  the  char- 
acter. With  this,  the  insight  of  the  patient  into  the  abnormality  of 
the  period  of  disease  through  which  he  has  passed  is  usually  incom- 
plete. Too,  the  physiognomy  usually  remains  pathologically  altered. 
Motor  disturbances  and  slight  attacks  of  vertigo  and  congestion 
occur  now  and  then,  and  betray  the  continued  existence  of  grave 
cerebral  changes. 

2.  Motor  Disturbances. — The  general  characteristics  are  their 
great  extent,  their  incompleteness,  their  variations  in  intensity  and 


570  SPECIAL  TATTIOLOGY  AND  THERAPY  OF  INSANITY. 

extent,  and  their  progressiveness,  with  tlie  character  of  disturhmice 
of  co-ordination. 

They  are  observed  in  speech,  in  the  voice,  the  ot-uhir  muscles,  tlie 
mnscles  of  facial  expression,  aiu1  in  the  extremities.  Speech  ami 
voice  nsnall}'  suffer  first. 

'I'lie  disturbance  of  si)ccch  is  essentially  a  distui'ljancc  of  co- 
ordination (stumbling  on  syllables):  as  a  result  of  the  demented 
conception  of  the  movements  necessary  for  the  entire  word  and  defect 
in  the  auditory  image  of  the  word,  or  partly  as  a  result  of  disturb- 
ance of  the  co-ordinating  mechanism  of  articulation  in  the  cerebral 
cortex,  the  formation  of  the  word  as  a  unit  takes  place  only  in  an 
incomplete  manner,  while  the  formation  of  the  sounds  and  syllables 
takes  place  without  trouble  (Kussmaul),  or  only  vowels  and  similar 
consonants  are  mistaken  one  for  another. 

In  the  course  of  the  disease  there  may  be  stammering,  stutter- 
ing, and  drawling,  as  well  as  temporary  aphasia  in  connection  with 
fluxionary  congestive  attacks;  and  finally  paralysis  of  the  tongue  may 
occur  after  apoplectiform  seizures. 

During  the  final  stage  the  loss  of  speech  is  due  to  the  combined 
effect  of  dementia,  aphasia,  and  complete  paralysis  of  co-ordination. 
During  rest  and  in  the  morning  the  disturbances  of  speech  are  more 
pronounced,  as  a  rule ;  after  the  speech-mechanism  has  been  in  activ- 
ity for  a  time — as,  for  example,  during  excitement — there  is  an 
increased  energy  in  it,  and  under  such  circumstances  the  disturbance 
of  speech  may  at  first  diminish. 

The  aphasia  is  in  the  beginning  purely  amnesic,  Init  further  in  the  course 
frequently  ataxic  apliasia  and  parapliasia  are  observed.  Tlie  articulatory  dis- 
turbance in  paralytics  depends,  in  part,  upon  ataxia  of  the  lips  (associated 
movements,  fibrilkxry  twitchings  of  the  orbicularis,  of  the  levator  labii  supe- 
rioris  alajque  nasi,  levator  menti,  and  later  also  paresis  of  the  upper  lip),  as  a 
result  of  which  the  differentiation  of  the  labials  and  dentals  is  interfered  witli 
(V,  w,  h,  p,  II,  s) ;  and  when  the  lips  are  too  much  pressed  together  the  speech 
may  even  be  temporarily  arrested. 

The  faster  the  patient  speaks  and  the  more  excited  he  is,  the  more  dis- 
tinct is  the  labial  ataxia,  which  the  patient  can  conceal  in  a  measure  when  he 
opens  his  mouth  as  little  as  possible.  The  glosso-articulatory  disturbance  of 
speech  co-ordination,  which  occurs  probably  only  in  dementia  paralytica  and 
which  is  called  "syllable  stumbling,"  is  more  important.  In  this  disturbance 
there  is  misplacing  or  mixing  of  syllables  and  letters,  whicli  is  especially  evi- 
dent when  tlie  patient  reads  aloud  (Ricger). 

With  this,  single  syllables  are  often  swallowed  or  only  incompletely  pro- 
nounced, because  the  innervation-impulse  to  pronounce  the  preceding  syllable 
continues,  or  that  for  the  following  syllable  occurs  too  early;  or  a  single 
syllable  is  repeated  (stuttering),  or  drawn  out  (drawling  speech),  because  the 


DISEASES  WITH  PREDOMINATING  TSYCHIC  SYMPTOMS.       571 

movements  for  pronunciation  in  the  first  case  are  spasmodically  repeated, 
and  in  the  second  case  the  speech-mechanism  is  insufTiciently  and  incorrectly 
innervated. 

Jn  the  final  stages  not  infrequently  speech  is  drawling  and  slowed,  be- 
cause the  patient  instinctively  seeks  to  overcome  the  difficulty  of  co-ordination 
by  more  prolonged  and  energetic  innervation.  However,  scanning  speech 
never  occurs.  The  disturbance  of  co-ordination  is  also  shown  frequently  in 
that  syllables  aie  unequally  and  incorrectly  accented,  some  being  subdued, 
others  unusually  accented. 

In  spite  of  extreme  disturbance  of  speech,  the  muscles  of  the  tongue  and 
lips  are  still  capable  of  performing  all  other  grosser  functions. 

The  disturbances  of  handwriting  (Erlenmeyer)  occur  early,  and 
are  important  because  they  point  to  diffuse  disease  of  the  cortex,  and 
especially  to  dementia  paralytica,  though,  as  Schule  proved,  cases  of 
paralysis  occur  in  which  there  is  no  disturbance  of  handwriting.  When 
they  do  occur  Erlenmeyer  rightly  emphasizes  their  diagnostic  im- 
portance with  reference  to  the  form  and  also  with  reference  to  the 
improvement  or  progress  of  the  disease. 

Alterations  in  the  handwriting  are,  according  to  the  autiior  mentioned, 
partly  psychosensorial  (dementia,  loss  of  memory-pictures  and  motor  ideas), 
partly  graph omechanical  (ataxia  combined  with  tremor).  In  the  first  case  the 
content  of  the  written  sentences  sufi'ers  as  a  result  of  omissions,  unnecessary 
repetitions,  and  the  misplacing  or  mistaking  of  letters,  syllables,  and  words 
(amnesic  or  ataxic  agraphia  and  paragraphia).  The  patient's  disturbed  intel- 
ligence prevents  recognition  of  the  written  errors.  In  the  second  ease  only 
the  graphic  form,  the  handwriting,  sufl'ers;  the  psychic  disturbance  of  writing 
precedes,  as  a  rule,  the  graphic.  In  the  final  stages,  with  the  loss  of  other 
ideas  of  moA^ement,  the  power  to  Avrite  is  absolutely  lost. 

Weiss,  and  later  Rabbas,  have  called  attention  to  a  peculiar  kind  of  dis- 
turbance of  reading.  It  approaches  paralexia  very  closely,  in  that  paralytics 
when  they  read  aloud  under  certain  circumstances  pronounce  the  greatest 
nonsense,  partly  in  the  form  of  distorted  words,  partly  in  words  of  new  forma- 
tion, instead  of  the  printed  text,  and  that  without  remarking  it.  Since  this 
disturbance  of  reading  occurs  often  very  early,  even  before  there  are  other 
signs  of  aphasia  and  disturbance  of  speech,  and  probably  onlj'  in  paralysis,  it 
may  have  diagnostic  value. 

The  vocal  muscles  are  often  early  disturbed  in  their  functions  by 
ataxia  and  paresis  (Schulz,  Rauchfuss),  and  thus  the  voice  frequently 
becomes  hoarse,  rough,  and  veiled,  takes  on  a  bleating  timbre,  and 
breaks  easily  in  singing.  As  a  result  of  disturbance  of  innervation 
of  the  soft  palate,  it  may  also  become  nasal. 

The  ocular  muscles,  especially  in  the  tabetic  form,  sometime? 
present  transitory  paralysis  with  diplopia;  nystagmus  and  ptosis  are 
also  observed  as  temporary  symptoms. 


572  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Anomalies  in  the  innervation  of  the  iris  are  frequent.  They  are 
only  significant  if  they  have  arisen  during  the  disease  and  intra- 
ocuhir  causes  can  be  excluded.^  ISTot  infreqiiently  in  the  beginning, 
especially  during  the  maniacal  stage,  there  is  myosis  that  disappears 
under  atropine.  More  frequently  theje  is  unilateral  mydriasis,  which 
does  not  yield  to  calabar.  But  the  inequality  of  the  pupils  and  the 
changes  and  disturbances  of  the  innervation  of  the  iris  are  especially 
important. 

In  the  domain  of  the  facial  there  are  often  very  early  changing 
pareses  limited  to  single  branches,  especially  to  those  of  the  lips. 
Widespread  paralysis  of  the  face  occurs  only  temporarily  after  apo- 
plectiform and  epileptiform  seizures.  An  early  symptom  is  fibrillary 
twitching  of  the  facial  muscles,  especially  of  those  about  the  mouth, 
which  occurs  notably  in  connection  with  movements  of  expression 
and  articulation,  and  which  temporarily  may  become  intensified  to 
the  degree  of  convulsive  tic.  In  the  advanced  stages  of  the  disease 
the  motor  portion  of  the  fifth  nerve  is  also  implicated.  As  a  result 
of  this  there  are  peculiar  automatic  spasmodic  movements  of  masti- 
cation and  grinding  of  the  teeth.  In  the  final  stages  of  the  disease 
the  muscles  of  deglutition  may  also  be  temporarily  insufficient,  with 
danger  of  suffocation. 

The  motor  disturbances  in  the  extremities  are  partly  cerebral 
and  partly  spinal.  The  loss  of  cerebral  activity  reveals  itself  in 
tremx)r,  muscular  insufficiency,  ataxia,  and  sometimes  also  in  inten- 
tion-tremor, but  more  particularly  in  the  lack  of  motor  ideas  and 
of  correct  valuation  of  the  muscle-sensations.  This  causes  acquired 
movements  to  become  heavy,  awlcward,  or  at  least  lacking  in  grace. 
The  gait  seems  badly  unbalanced.  To  these,  other  disturbances  are 
added :  a  result  of  changes  in  the  conducting  paths  in  the  spinal  cord. 

There  are  cases  of  exquisite  tabetic  gait  with  loss  of  the  deep  reflexes, 
usually  at  the  same  time  associated  with  loss  of  the  oculo-pupillarj^  reflexes, 
evidently  due  to  gray  degeneration  of  the  posterior  columns.  IMore  frequently 
the  gait  is  slightly  spastic,  or  at  least  stiff  and  mechanical,  with  striking  of 
the  heel.  In  these  cases  the  deep  reflexes  are  increased,  and  sometimes  even 
foot-clonus  can  be  elicited.  This  disturbance  of  the  gait  is  found,  in  the  main, 
in  the  classic  form  of  paralysis,  and  is  possibly  due  to  disturbed  reflex  inhibi- 
tion, dependent  upon  hydrocephalus,  as  well  as  upon  changes  in  the  posterior 
portions  of  the  lateral  columns  of  the  cord.  The  state  of  the  deep  reflexes 
has  been  studied  by  Crump,  Beatly,  Beilencourt,  and  others.  The  first 
observer  mentioned  foimd  in  65  cases  that  tlie  patellar  reflexes  were  wanting 


'Pupillary  anomalies  (central)  may  long  precede  other  signs  of  paretic 
dementia  and  tabes;  they  are  often  early  signs  of  the  possible  development 
of  these  diseases,  for  the  Argyll  Robertson  pupil  is  more  and  more  regarded 
as  a  sign  of  syphilitic  infection. — Translator. 


DISEASES  WITH  PREDOMINATING  PSYCTIIC  SYMPTOMS.       573 

18  times  and  exaggerated  26  times.     Tlie  second  observer  in  G8  cases  found  the 
patellar  reflexes  absent  11  times  and  increased  43  times. 

The  apoplectiform  and  epileptiform  seizures  are  very  important 
episodic  manifestations.  The  apoplectiform  attacks  are  incomplotf, 
limited  to  a  momentary  loss  of  consciousness  with  reduction  of  inner- 
vation; or  they  resemble  perfectly  the  apoplectiform  attack  with 
hemiplegia,  from  which  they  differ  only  in  the  rapid  disappearance 
of  the  paralysis  and  the  simultaneous  elevation  of  bodily  temperature. 

The  epileptiform  attacks  may  resemble  attacks  of  genuine  epi- 
lepsy. More  frequently  they  are  only  partial,  unilateral,  and  not 
accompanied  by  complete  loss  of  consciousness.  Besides,  they  hist 
long,  even  hours  or  days;  in  rare  cases  they  are  limited  to  momentary 
attacks  of  vertigo.  These  attacks  very  frequently  are  due  to  vascular 
paralysis  with  violent  cerebral  congestion  and  elevation  of  the  tem- 
perature of  the  head  1.5°  C.  above  that  in  the  axilla  (Reinhard). 
After  these  attacks  there  are  frequently  inflammatory  affections  of 
the  lungs  (catarrhal  and  hypostatic  pneumonias),  the  nature  of  which 
(whether  mechanical  and  due  to  the  passage  of  the  secretion  of  the 
throat  and  mouth  into  the  air-passages,  or  neurotic  and  due  to  vas- 
cular paralysis  in  the  domain  of  the  sympathetic)  is  still  in  doubt. 
Eare  forms  of  seizures  are  tetaniform  and  hystero-epileptic  attacks. 

The  seizures  may  occur  in  any  stage  of  the  disease.  They  do  not 
occur  in  every  case,  though  they  are  very  frequent;  as  a  rule,  they 
are  frequently  repeated  if  they  have  once  occurred  in  the  disease. 
After  such  attacks  the  motor  disturbances  are  increased,  and  often 
for  a  considerable  period  there  is  left  paralysis  of  the  facial,  hypo- 
glossus,  and  hemiparesis,  which,  if  they  follow  convulsions,  always 
affect  the  side  that  has  been  affected  in  the  seizure.  As  a  rule,  these 
paralj^ses  disappear  in  a  few  hours  or  days.  x\fter  such  seizures  the 
mental  condition  is  always  worse,  and  the  mind  never  gets  back  to  its 
former  level. 

These  seizures  are  certainly  not  due  to  gross  anatomic  changes.  The 
apoplectiform  attaclvs  probably  are  due  to  temporary  vascular  paralysis  with 
consecutive  regional  edema  in  certain  portions  of  the  motor  area. 

The  epileptiform  attacks  are  probably  due  to  recurring  irritative  proc- 
esses in  the  motor  areas  of  the  cortex.  This  irritation  may  be  direct  (Bech- 
terew calls  attention  to  the  frequency  of  cysts  between  the  arachnoid  and  the 
cerebral  surface)  or  peripheral  (as,  for  example,  overfilling  of  the  bladder),  the 
influence  of  Avhich,  in  the  functional  state  of  excitability  in  the  motor  areas, 
is  comprehensible. 

3.  Vasomotor  Disturbances.— These  are  early  revealed  in  the 
monocrotic,  slow  character  of  the  pulse.  In  this  disease  there  is  a 
progressive  vascular  paresis  which  temporarily  may  lead  to  total 


574  SPEOAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

regional  vascular  paralysis  in  the  domain  of  the  cervical  sympathetic 
(often  unilateral  like  that  caused  by  Claude  Bernard's  sections),  with 
attacks  of  vertigo  and  apoplex}',  local  and  general  elevation  of  tem- 
]ieraturi\  unilateral  sweating,  etc.;  and  it  nuiy  also  appear  in  tlio 
form  of  circumscribed  vascular  paralysis  in  the  skin  (meningitic 
spots — Trousseau).  In  the  final  stage  this  vascuhir  ]iaralysis  is  gen- 
eral, and  causes,  along  witli  neuro-paralytic  bypereinia  in  the  hmgs, 
bladder,  intestines,  etc.,  cyanosis,  coolness^  and  eileiua  of  the  skin, 
and  subnormal  temperature. 

4.  A.Aroxc  TiiK  'I'koimiic  Disturbances  arc  to  be  mentioned 
herpes  zoster  as  not  infrequent;  bloody  sweating,  first  oliserved  by 
Servaes;  rapid  loss  of  -weight  in  the  final  stage;  fragilitas  osseum 
with  increase  of  phosphates  in  the  urine;   and  the  final  decubitus. 

5.  Compared  with  the  vasomotor  and  motor  disturbances,  the 
disturbances  of  sensibility  play  but  a  small  part. 

Not  infrequently  in  the  beginning  there  is  headache;  lancinat- 
ing pains  occur  in  the  extremities  only  in  the  tabetic  form.  In  tlie 
ad\anced  stages  of  paralysis,  sensibility  is  reduced,  but  exact  investi- 
gation of  it  is  difficult  on  account  of  the  dementia  and  disturbed 
consciousness.  In  many  cases  tactile  sensibility  is  retained  and  sensi- 
bility to  pain  absent.  Under  such  circumstances  there  is  danger  of 
self-mutilation,  and  such  patients  require  careful  watching.  There 
have  been  cases  in  which  analgesic  paralytics  have  burned  themselves 
most  seriously,  bitten  out  the  tongue  and  chewed  the  morsels,  or  gone 
about  with  compound  fractures  of  the  leg. 

6.  Sensorial  Disturbances. — In  dementia  paralytica  hallucina- 
tions are  remarkably  infrequent,  so  infrequent  that,  when  they  occur, 
doubt  as  to  the  correctness  of  the  diagnosis  should  be  entertained, 
and  the  possibility  of  alcoholic  paralysis  considered.  In  the  classic 
form  of  paralysis  there  may  be  visual  hallucinations,  especially  dur- 
ing states  of  excitement.  Fürstner  has  shown  the  existence  of  inter- 
esting defects  in  the  visual  cortical  areas  in  the  form  of  psychic 
blindness,  which  sometimes  improves,  but,  as  a  rule,  advances  to 
cortical  blindness.  Amblyopia  due  to  infracortical  disturbances  in 
the  optic  tracts  is  not  infrequent,  both  as  a  symptom  in  the  pro- 
dromal stage  and  during  the  course  of  the  disease.  Along  with 
negative  findings  the  ophthalmoscope  reveals  neuroretinitis  and 
peripapillary  edema.  Flemming,  Westphal,  Simon,  and  Magnan  have 
observed  cases  of  anosmia.  In  a  few  cases  gray  degeneration  of 
the  olfactory  nerves  has  been  found. 

7.  The  Sexual  Desire^  in  the  initial  stages  of  the  disease,  as 
well  as  during  the  episodic  states  of  excitement,  is  usually  increased. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       575 

sometimes  also  perverse;  in  the  final  stages  of  the  mahidy  liljido  and 
sexual  power  are  usually  destroyed. 

8.  Paralytic  dementia  presents  deviations  from  the  normal 
variations  of  temperature. 

Reinhard  found,  on  tlie  wliole,  that  tlie  noon  and'nvcnin^  ioniporaliires 
were  higher  than  the  morning  temperatures.  Not  infrequently  there  are 
episodic  increases  of  bodily  temperature,  which,  however,  are  not  to  be  taken 
as  evidence  of  the  inflammatory  nature  of  the  disease  without  further  consid- 
eration, but  rather  are  to  be  explained  as  temporary  functional  disturbances 
of  the  temperature  centers  in  the  cerebral  cortex.  Fever  (40°  C.)  that  sinks 
quickly  after  the  emptying  of  an  overfilled  bladder,  or  of  the  intestines,  is  to 
be  regarded  as  nervous;  as  are  hyperpyretic  temperatures  during  the  agony 
(45°  C.  in  a  case  in  which  I  personally  used  the  thermometer).  * 

Elevations  of  temperature  to  40°  C.  are  quite  common  in  the  states  of 
excitement  of  the  paralytic,  and  also  as  accompanying  manifestations  of  con- 
gestive, apoplectiform,  and  epileptiform  seizures  (vasomotor  paralysis  in  the 
domain  of  the  cervical  sympathetic).  They  take  place  under  such  circum- 
stances from  ten  to  twelve  hours  before  the  attack  (Reinhard),  and  outlast 
these  several  hours  or  days.  Krömer  has  observed  abnormal  depression  of  the 
body-temperature,  especially  in  the  hypochondriac,  tabetic,  and  demented 
forms  of  paralysis. 

In  the  final  stages  of  the  disease  the  temperature  is  subnormal.  Differ- 
ences in  temperature  of  the  two  sides  of  the  body  reaching  as  high  as  1°  C.  are 
not  infrequent,  especially  after  seizures.  Just  before  the  agony  there  may  be 
collapse  temperatures  as  low  as  24°  C,  with  subjective  feeling  of  well-being. 

The  diagnosis  of  dementia  paralytica  is  easy  when  the  disease  is 
developed,  and  when  a  history  and  knowledge  of  the  course  of  the 
disease  are  obtainable. 

Though  no  single  symptom  is  pathognomonic  of  the  disease,  yet 
on  the  mental  side,  the  foundation  of  psychic  weakness  upon  which, 
from  the  beginning,  the  varying  psychic  conditions  develop  and  run 
their  course,  and  the  peculiar  manner  of  development  and  grouping 
of  the  symptoms,  vasomotor  and  motor,  afford  sure  indications  for  the 
diagnosis.  With  this  there  is  the  development  out  of  a  jorodromal 
stage,  indicating  a  peculiar,  or  at  least  grave,  idiopathic  brain  disease, 
and  the  progressive  changeable  character  of  the  various  series  of 
symptoms,  with  tendency  to  remissions. 

The  differentiation  of  the  melancholic  and  maniacal  pictures,  of 
the  delusions  of  grandeur,  and  of  the  episodes  of  furious  mania,  from 
the  non-paralytic  forms  has  already  been  considered,  as  well  as  the 
differentiation  of  certain  forms  of  chronic  alcoholism  (vide  page  537). 
With  reference  to  focal  brain  diseases  with  mental  disturbance  (de- 
mentia after  apoplexy,  encephalitis),  it  is  to  be  remembered  that  the 
motor  disturbances  of  general  paralysis  are  not  paralysis,  but  dis- 


576  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

turbances  of  co-ordination,  general  and  not  circumscribed  in  their 
extent,  varying  in  intensity  and  extent,  and  that  they  are  progressive 
and  not  stationary. 

The  differential  diagnosis  from  certain  cases  of  cerebral  syphilis 
may  be  difficult,  on  account  of  the  existence  of  diffuse  degeneration  of 
the  vessels  and  tissues.  Aside  from  the  general  symjitoms  indicating 
cerebral  syphilis,  the  infrequeney  of  delusions  of  grandeur,  the  spe- 
cial prominence  of  paralysis  of  single  cranial  nerves,  and  the  early 
age  in  cerebral  sypliilis  often  afford  indications. 

Among  the  most  difficult  tasks  is  to  recognize  paralysis  in  those  rare 
cases  in  which  secniiiigly  an  ordinary  psychononrosis  has  forine<l  tlie  pro- 
dromal stage. 

In  harmony  with  Schule,  I  have  observed  cases  in  which  there  was  no 
symptom  to  indicate  threatening  paralysis,  and  in  which  any  suspicion  of  its 
existence  had  to  be  abandoned,  and  yet  in  wliich,  after  apparent  or  actual 
subsidence  of  the  psychosis,  the  picture  of  paralysis  developed.  With  refer- 
ence to  psychoses  under  such  circumstances,  in  individuals  of  mature  years 
that  are  high  livers  and  given  to  great  mental  activity,  there  is  suspicion  of 
paralysis  if  symptoms  of  change  of  character  and  cerebral  asthenia  preceded 
the  psychosis,  or  if  the  psychosis  presents  severe  organic  features  in  its 
course:  as  a  melancholia,  for  example,  noticeable  for  absence  of  affect  with 
nihilistic  delusions;  or  a  mania  presenting  signs  of  grave  cerebral  irritation 
reaching  the  degree  of  acute  delirium  episodically.  The  suspicion  is  propor- 
tionately strengthened  if  states  of  stupor,  vascular  spasms,  and  attacks  of 
vertigo  be  intercurrent;  if  lapses  of  memory  and  judgment  be  noticeable; 
if  without  somatic  cause  elevation  of  temperature  occur;  and  finally  if  the 
subsidence  of  the  psycliosis  be  not  entirely  satisfactory,  but  leave  signs  of 
mental  weakness  behind. 

'No  less  difficult  and  still  prognostically  very  important,  is  the 
differentiation  of  mere  functional  cerebral  exhaustion  (cerebral  neu- 
rasthenia) from  the  initial  stage  of  paralysis.^ 

In  the  beginning  the  two  diseases  may  be  almost  exactly  alike,  and, 
indeed,  it  cannot  be  doubted  that  paralysis  may  develop  out  of  cerebral  neu- 
rasthenia if  the  blood-vessels  are  abnormally  permeable;  and  thus  the  vaso- 
motor cerebral  neurosis  may  become  an  organic  disease. 

At  any  rate,  in  such  doubtful  cases  the  etiology  must  be  consideied 
above  all.  The  exciting  causes  (mental  strain,  mental  shock,  etc.)  may  be  the 
same  in  both  diseases,  but  there  is  a  difference  between  the  predisposing  con- 


'■  A  very  valuable  aid  in  the  differentiation  of  dementia  paralytica  from 
so-called  neurasthenic  conditions  is  afforded  by  examination  of  the  cerebro- 
spinal fluid  (lumbar  puncture).  Lymphocytosis  and  the  presence  of  an  ab- 
normal quantity  of  serum-albumin  are  indicative  of  disease-processes  affecting 
the  meninges,  and  in  a  doubtful  case  would  afford  reliable  evidence  of  disease 
of  the  central  nervous  system. — Translatob. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       577 

ditions,  which  in  neurasthenia  consist  essentially  of  neuropathic  and  usually 
hereditary  taint,  but  which  in  paralysis  are  acquired  conditions  like  rickets, 
head  injury,  alcoholism,  and  especially  syphilis.  If  the  latter  predisposing 
causes  are  present  in  men  at  the  height  of  maturity  who  have  been  high 
livers,  and  at  the  same  time  under  mental  strain,  and  signs  of  cerebral  neuras- 
thenia are  presented,  then  paralysis  should  be  suspected  rather  than  cerebral 
neurasthenia.  There  must  be  even  greater  care  if,  besides,  tabetic  symptoms 
can  be  demonstrated.  On  the  other  hand,  if  suspicious  symptoms  occur  at  an 
early  age,  up  to  about  35,  and  if,  besides,  the  individual  is  nervously  predis- 
posed and  has  not  been  exposed  to  excesses  in  potu  et  venere,  and  is  free  from 
syphilis,  then  the  weight  of  opinion  should  be  in  favor  of  mere  cerebral 
neurasthenia. 

With  the  etiology  of  the  ease,  the  manner  of  its  development  is  of  im- 
portance. An  almost  sudden  giving  out  of  the  cortical  activities,  ■  especially 
if  it  follow  upon  a  mental  shock,  speaks  for  cerebral  neurasthenia,  while  an 
insidious  or  interrupted  development  of  the  symptoms  speaks  for  paralysis. 
Continued  maxked  change  of  character,  signs  of  loss  in  the  ethic  sphere, 
marked  hypochondriac  depression  with  absurd  explanation  of  it,  speak  for 
paralysis;  simple  emotionality,  irritability  reaching  the  intensity  of  uncon- 
trollable affects,  abnormal  egotism  reaching  the  degree  of  quarrelsomeness, 
and  nosophobic  ideas  of  brain  softening  with  consequent  dysthymia,  belong  to 
cerebral  neurasthenia.  Weakness  of  memory  occurs  in  both  diseases,  but  tlie 
loss  of  memory  in  paralysis  is  more  marked,  more  lasting,  and  progressive, 
and  is  an  actual  loss — that  of  the  asthenic  is  objectively  out  of  harmony  with 
his  complaints,  changeable  in  its  intensity,  merely  a  phenomenon  of  fatigue 
(with  virtual  retention  of  memory),  Avhich  during  phases  of  mental  exhaustion 
may  manifest  itself  in  decided  difficulty  of  writing  and  speaking  that  may 
attain  the  degree  of  aphasia.  If  Ave  accept  temporary  and  changeable  diffi- 
culty in  the  activity  of  the  psychic  powers,  the  patient  suffering  with  cerebral 
neurasthenia  does  not  present  disturbance  of  intelligence,  any  more  than 
clouding  of  the  sensorium.  Such  indications  of  actual  loss,  however,  occur 
often  very  early  in  paralytics,  are  painfully  evident,  and  cause  him  to  be 
impossible  in  society.  The  patient  suffering  with  cerebral  neiirasthenia,  since 
he  thinks  himself  demented  and  uncertain  in  social  intercourse,  constantly 
fears  that  which  actually  takes  place  in  the  paralytic;  but  since  he  is  virtu- 
ally intact,  offense  against  good  manners  and  defects  in  general — writing  and 
conduct — do  not  occur.  He  makes  slips  of  the  pen,  but  he  notices  and  corrects 
the  errors  due  to  fatigue,  in  contrast  Avith  the  paralytic. 

Obstinate  sleeplessness  in  spite  of  all  hypnotics,  falling  asleep  in  inap- 
propriate places,  in  society  during  the  daytime,  afford  ground  for  suspicion  of 
paralysis. 

Apoplectiform  and  epileptiform  attacks,  attacks  of  aphasia,  temporary 
monoplegias,  paralysis  of  the  tongue  Avith  paresthesia  and  ophthalmic  migraine 
as  recent  disturbances,  do  not  belong  to  neurasthenia,  but  indicate  organic 
disease.  Phosphaturia  is  very  common  in  the  initial  stage  of  paralysis; 
uraturia  and  oxaluria  belong  to  neurasthenia.^ 


^  Early  polyuria  of  short  duration  is  a  suspicious  symptom  in  non- hysteric 
patients. — Tkanslatob. 

37 


578  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

The  duration  of  ilie  disease  in  gonoriil  is  very  variable  and  diffi- 
cult to  prognosticate,  ior  the  period  at  whicli  the  prodromal  changes 
came  on  is  ditlicult  to  ascertain.  On  an  average,  the  disease  lasts 
about  three  years.  In  aged  persons  and  in  females  it  lasts  decidedly 
loiiger.  Cases  due  to  mental  exhaustion  and  head  injury  seem  to  have 
a  longer  course  than  those  due  to  excesses  in  haccho  et  vencre. 

Of  bad  omen — i.e.,  indicating  a  more  rapid  course — are  occa- 
sional fever,  early  occurrence  of  disturbances  in  the  handwriting  and 
movements,  early  and  frequent  paralytic  or  other  seizures.  The 
hypochondriac  and  demented  forms  permit  expectation  of  a  slower 
course  than  does  the  classic  form.  But  the  course  and  duration  in  a 
given  case  cannot  be  prognosticated;  for  even  in  the  advanced  stages 
remissions  and  arrest  lasting  weeks  or  months  are  still  possible.  In 
rare  cases  dementia  paralytica  ends  witliin  a  few  months  or  a  year 
(acute  or  galloping  paralysis). 

As  in  acute  delirium,  Ave  liave  here  to  deal  with  an  invalid  brain.  A 
new  excess,  any  psychic  or  physical  trauma  (insolation,  etc.;,  may  cause  the 
outbreak  of  the  disease.  The  symptoms  of  loss  and  irritation  are  essentially 
those  of  the  chronic  form,  only  they  develop  and  run  their  course  in  a  stormy 
way,  corresponding  with  tlie  acuteness  of  the  anatomic  process.  The  stajje  of 
incubation  lasts  a  few  days  or  weeks  (fluxion,  headache,  sleeplessness,  mental 
dullness,  intellectual  and,  especially,  ethic  defects,  jn"eat  emotional  irrita- 
bility). Then  one  day  furious  mania  breaks  out,  with  profound  disturbance 
of  consciousness,  wild  flight  of  ideas,  senseless  grand  delusions,  often  inter- 
mixed with  those  of  micromania.  With  this,  there  is  violent  congestion,  often 
fever,  fibrillary  twitchings  of  the  muscles  reaching  the  degree  of  slight  con- 
vulsions, grinding  of  the  teeth — all  as  signs  of  severe  cerebral  irritation. 
During  the  course  there  is  very  marked,  forced  movement,  with  smearing,  teai-- 
ing,  and  destroying.  After  a  few  days  or  weeks  there  is  quiet,  but  there 
remains  profound  dementia,  paresis,  ataxia,  aphasia,  hesitating  and  stumbling 
speech,  as  signs  of  the  profound  injury  the  motor  areas  of  the  cortex  have 
undergone.  With  renewed  signs  of  cerebral  irritation  (outbreaks  of  furious 
mania,  epileptiform  and  apoplectiform  seizures)  the  mental  destruction  is 
completed  within  a  few  weeks  or  months.  This  is  followed  by  physical 
decay — marasmus,  decubitus,  reduction  of  general  innervation,  finally  involv- 
ing the  vital  centers,  and  thus  the  fatal  termination  is  prepared,  which  takes 
place  in  profound  cxliaustion  or  sometimes  in  convvilsions. 

The  striking  findings  postmortem  are:  Congestion,  adhesion  of  the  pia 
to  the  cortex,  which  is  gray-red,  with  local  areas  of  softening,  especially  in  the 
central  convolutions.  Capillary  apoplexies  ai-e  not  infrequent.  Microscopic- 
ally the  lymph-sheaths  appear  filled  with  white  and  red  blood-corpuscles,  the 
glia  thickened  (enormous  multiplication  of  spider  cells  and  nuclear  prolifera- 
tion), and  the  ganglion-cells  are  formd  in  a  condition  of  cloudy  swelling  and 
distension. 

The  prognosis  of  dementia  paralytica  is  unfavorable,  in  spite  of 
rare  recovery,  which,  however,  may  always  be  called  in  question, 


DISEASES  WITH  PREDOMINATING  rSYCIIIC  SYMPTOMS.       570 

either  with  reference  to  the  diagnosis  of  the  disease  or  the  fact  oE 
recovery  (simple  remission).  We  cannot,  however,  with  ahsolijte  cer- 
tainty pronounce  a  sentence  of  death  from  a  medical  standpoint  on 
such  patients. 

In  modern  literature  cases  of  recovery  wliich  bear  the  most  rigid  criti- 
cism are  increasing  in  number.  In  most  cases,  bovvev(!r,  the  reports  are 
published  too  early  to  allow  a  decisive  judgment;  or  tlie  recovery  was  not 
pure,  states  of  mental  weakness  remaining;  or  the  condition  was  one  merely 
of  intermission,  the  disease  recurring  and  not  beginning  anew,  but  wlicre  it  left 
off,  the  intermission  having  been  merely  a  latent  period. 

Tnese  objections  hold  good  in  great  part  for  the  cases  reported  by  Voisin 
in  his  monograph  (pages  192  and  521),  and  for  the  numerous  cases  (30)  re- 
ported by  Doutrebente,  in  which  recovery  was  frequently  the  result  of  profuse 
suppuration,  abscesses,  injuries;  and  in  part  also  for  the  cases  of  recovery 
reported  by  Gauster. 

Cases  of  undoubted  recovery  have  been  published  by  Flemming  {Irren- 
freund,  1877,  H.  1-2),  Schule  (ZeitscJirift  für  Psyclilatrie,  32,  H.'6),  Gauster 
{Psychiatrisches  Ceiitralblatt,  1875,  1-2),  and  Oebeke  (Zeitschrift  für  Psuchi- 
atrie,  36,  H.  6).  See  iuriher -Afinales  wcdico-psycholnfjiqiws,  1879,  May  (Irren- 
freund,  1879,  8);  Stölzner,  Irreiifrrinid.  1877,  8;  Nasse,  idem,  1870,  7;  L. 
Meyer,  Berliner  klinische  Wochenschrift,  1878,  21.  Nasse  (Zeitschrift  für 
Psychiatrie,  42,  H.  4),  follovv-ing  Oebeke,  gives  all  the  literature  of  the  subject 
since  1879,  and  from  his  own  rich  experience  makes  the  very  discouraging 
statenient  that  since  1872  he  has  never  seen  a  case  of  recovery,  and  that,  of 
his  7  cases  of  recovery  reported  in  1870,  6  had  relapses  and  died  of  severe 
cerebral  seizures.  Only, in  a  single  case  was  the  recovery  maintained,  though 
during  the  disease  there  was  no  disturbance  of  speech,  so  that  the  diagnosis 
is  doubtful. 

In  SO  severe  a  disease,  that  grows  more  and  more  frequent,  its 
etiology  is  of  very  special  interest. 

Modern  investigation  has  recognized  the  fact  that  general  paral- 
ysis stands  in  very  close  relation  to  syphilis,  and,  the  more  carefully 
the  history  of  patients  is  studied,  the  higher  is  the  percentage  of 
paralytics  that  have  certainly  or  probably  been  infected  with  syphilis. 
Hirschl  ("Jahrbuch  für  Psychiatrie,"  xiv,  3)  found  that  of  175  male 
paralytics  in  my  clinic  98  (56  per  cent.)  had  previously  had  lues  and 
44  (35  per  cent.)  had  probably  been  infected. 

With  reference  to  the  remaining  33  cases  (19  per  cent.),  in  w^hom 
infection  was  entirely  doubtful,  this  observer  notes  that  in  63  cases  of 
late  forms  of  syphilis  in  Langes  service  in  Vienna  only  54  per  cent, 
'could  be  proved  with  certainty  to  have  had  lues,  9.5  per  cent,  probably 
had  been  infected,  and  in  36.5  per  cent,  there  was  no  proof  of  early 
luetic  disease;  so  that  in  these  33  cases  of  paretic  dementia  the  possi- 
bility that  primary  infection  was  overlooked  cannot  be  denied;  the 
more  because  paralysis  in  those  that  have  suffered  with  syphilis  may 


580  fTECTAL  rATIlOLOGY  AND  THERAPY  OF  INSANITY. 

not  develop  until  25  years  after  infection,  although,  as  a  rule,  the 
outbreak  occurs  from  5  to  15  years  later. 

That  previous  syphilis  is  the  most  important  predisposition  for 
the  subsequent  development  of  paralysis  is  shown  l)y  its  infrequency 
in  children  and  youthful  persons,  in  whom  it  can  almost  without 
exception  be  referred  to  lues,  especially  hereditary;  its  infrequency 
in  women  in  the  higher  classes  of  society  and  in  the  clergy;  its 
great  frequency  among  single  men  of  large  cities,  especially  in  the 
army;  its  great  frequency  in  cosmopolitan  centers  of  population,  in 
contrast  with  tlie  country  (8  to  1) ;  its  striking  infrequency  in  regions 
Avhere  lues  occurs  only  sporadically  (Eabow — Canton  Wallis);  the 
relative  difference  between  its  occurrence  in  men  and  women  (1-3.5 
to  1),  and  the  fact  that  it  is  exactly  parallel  with  the  occurrence  of 
lues  in  the  population  for  the  two  sexes. 

The  age  at  which  paralysis  develops  (35  to  50)  is  immediately 
explained  when  it  is  remembered  that  luetic  infection  occurs,  for  the 
most  part,  between  the  ages  of  20  and  30,  and  that,  on  an  average, 
the  outbreak  of  paralysis  occurs  in  from  5  to  15  years  after  infection. 

Whether  paralysis  occurs  exclusively  in  those  tliat  are  syphilitic 
is  at  the  present  time  no  more  surely  determined  than  the  question 
by  means  of  what  process  lues  exercises  its  pathogenic  influence.  It 
has  been  assumed  (Mendel)  that,  like  syphilitic  interstitial  hepatitis, 
it  induces  interstitial  encephalitis,  or  that  it  causes  minute  changes 
in  the  cerebral  vessels,  as  a  result  of  which  they  become  abnormally 
permeable.  Others  assume  the  cause  of  the  tissue-changes  in  paral- 
ysis to  be  a  toxin  (Strümpell)  or  a  ferment-like  poison  developed 
under  the  influence  of  lues  (Möbius — paralysis  a  "metasyphilitic" 
disease).  It  is  certain,  however,  that  paralysis  is  not  a  specific  (luetic) 
brain  disease  either  in  the  sense  of  a  gummatous  or  arteritic  process, 
which  explains  the  failure  of  antisyphilitic  treatment. 

Undoubtedly  the  preceding  luetic  infection  is  the  most  important 
predisposing  cause  of  paralysis,  and  in  contrast  with  the  majority 
of  the  psychoses  it  is  to  be  regarded  not  so  much  an  hereditary  as  an 
acquired  and  preventable  disease. 

But  only  a  certain  percentage  of  those  affected  with  lues  develop 
paralysis,  and  this  supports  the  assumption  that  there  are  other  pre- 
disposing causes  which  lessen  the  resistive  power  of  the  brain,  as  well 
as  accessory  causes. 

Hereditary  taint  plays  but  a  subordinate  role  (about  15  per 
cent.)  in  contrast  with  an  acquired  neuropathic  state  due  to  other 
causes.  In  relation  to  this  point  I  found  the  rachitic  cranium  re- 
markably frequent. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       581 

Various  observers  have  been  struck  with  the  frequency  with 
which  a  tendency  to  cerebral  congestion  and  apoplexy  is  found  in  the 
ancestry  and  blood-relations  of  paralytics. 

Among  accessory  causes  may  be  mentioned  physical  and  mental 
over-exertion,  especially  in  positions  of  great  responsibility;  dissolute 
life,  especially  continued  alcoholic  and  sexual  excesses,  the  first  of 
which,  however,  are  decidedly  overestimated;  and  sometimes  also 
head  injuries  and  caloric  influences. 

In  women  the  changes  incident  to  the  climacteric  are  very  fre- 
quently the  exciting  cause  of  the  outbreak  of  the  disease. 

A  very  rema-rkable  fact  is  the  occurrence  of  paralysis  in  child- 
hood and  youth;  it  was  first  recognized  in  1877.  More  than  50  cases 
have  now  been  reported.  At  the  present  time  in  my  clinic  there  are 
4  infantile  paralytics  (3  males,  1  female). 

Alzheimer  has  recently  described  these  "early  forms  of  paralysis."  Of 
41  cases  which  he  has  collected  from  literature  and  in  his  own  practice,  there 
were  20  males  and  21  females.  In  3  cases  the  disease  began  at  the  age  of  10. 
From  this  time  on  its  frequency  increases,  being  greatest  from  15  to  16 
(puberty) ;  it  then  diminishes  up  to  the  twenty-second  year.  The  average 
duration  of  the  diseas'e  is  4V2  years  (in  5  cases  over  7  years).  Hereditary 
taint  existed  in  86.6  per  cent,  of  the  cases;  and  general  paralysis  in  the  father 
and  mother  is  remarkably  frequent.  In  91  per  cent,  of  the  cases  hereditary 
lues  was  certain  or  probable. 

One  of  my  patients,  a  student,  aged  23,  had  been  suffering  two  years  with 
dementia  paralytica,  which  was  said  to  have  arisen  after  overwork  for  exam- 
inations. His  father  developed  the  same  disease  at  the  age  of  49.  It  was 
established  that  the  father,  at  the  time  of  the  conception  of  this  son  (the 
eldest)  Avas  still  suffering  with  lues.  The  wife  and  two  younger  children  of 
this  father  are  free  from  lues  and  have  thus  far  been  healthy. 

The  noteworthy  clinical  peculiarities  of  this  early  form  of  paral- 
ysis may  be  stated,  in  accord  with  Alzheimer,  to  be:  exclusively 
23rimary  demented  form  of  the  disease  (episodic  disease-pictures  of 
different  kind  not  excluded)  ;  insidious  course  as  in  the  adult;  inter- 
ference with  further  evolution  of  the  body;  very  frequent  paralytic 
attacks;  early  and  often  very  marked  symptoms  of  paralysis;  very 
frequent  loss  of  the  patellar  reflex  and  optic  atrophy,  and  especially 
tabetic  symptoms. 

In  the  actual  state  of  our  knowledge  of  the  disease  clinically, 
anatomically,  and  etiologically,  the  necessity  of  learning  the  patho- 
genesis of  this  fearful  malady,  which  is  becoming  more  and  more 
frequent,  is  imperative. 

The  cafnit  mortuum  of  the  disease  process  in  general  paralysis 
and  the  anatomic  substratum  of  the  clinical  symptoms  of  loss  is 
cerebral  atrophy.     This  differs  neither  macroscopically  nor  micro- 


582  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

scopicall}'  from  atroph}^  due  to  other  causes,  except  in  its  localization 
(almost  exclusively  in  the  i'orebrain)  and  its  intensity;  for  the  "weight 
of  the  brain  may  be  reduced  to  the  sixth  part  of  its  normal  weight, 
while  atrophy  of  any  other  kind  rarely  exceeds  a  loss  of  one-twentietli 
part.  How  tliis  excessive  cerebral  atrophy  arises  cannot  be  decided. 
Jt  is,  in  llio  next  place,  remarkable  that  the  domain  of  the  vertebral 
arteries  escapes  almost  entirely.  For  those  that  accept  the  hypothesis 
tliat  paretic  dementia  is  a  nietasyphiiitic  disease,  the  elective  ])o\vor  of 
the  hypothetic  toxin  upon  the  vascular  area  of  the  internal  carotid, 
somewluit  analogous  to  the  elective  choice  of  the  posterior  columns  in 
the  disease-process  of  tabes,  is  inexplicable.  On  the  other  hand,  it  is 
to  be  urged  that  many  of  the  injurious  influences  which  assist  in  the 
development  of  general  paralysis  (mental  over-exertion,  emotional  ex- 
citement, sexual  excesses,  etc.)  first  and  most  intensely  affect  the 
forebrain. 

Processes  affecting  the  vessels  play  a  most  imjDortant  part  in  the 
disease-process  of  general  paralysis. 

Many  etiologic  influences  in  the  causation  of  paralytic  dementia 
(mental  exertion,  especially  those  associated  with  emotional  excite- 
ment) are  alike  in  this,  that  the}^  lead  to  functional  hyperemia  of  the 
forebrai]!,  and  more  readily  during  biologic  phases,  when  the  brain 
is  naturally  in  a  state  of  physiologic  turgescence  (full  maturity)  or 
disposed  to  congestion  (climacteric). 

"^I'liis  possible  functional  hyperemia,  owing  to  continuance  of 
irritation  or  to  the  continued  activity  of  influences  which  paralyze 
the  vasoconstrictors  (alcohol,  heat-stroke,  injury,  etc.),  passes  over 
into  neuro-paralj'tic  hyperemia.  All  depends  on  whether  the  vessel- 
walls  are  intact  in  structure — that  is,  abnorinally  permeable — or  not. 
It  is  certain  that  lues  changes  the  vessel-walls,  and  probably  renders 
them  abnormally  permeable.  The  same  is  true  of  other  infectious 
diseases,  severe  general  diseases,  chronic  intoxications  (alcohol),  and 
probably  also  of  rickets.  But  the  disease-process  in  general  paralysis 
as  such  early  leads  to  changes  in  the  vessel-walls  (hyaline)  which 
favor  the  increase  of  permeability  of  the  vessels. 

The  necessary  result  of  this  abnormal  permeability  is  transuda- 
tion of  the  elements  of  the  blood  into  the  perivascular  and  inter- 
adventitial  spaces  in  the  form  of  colloid  and  albuminous  materials, 
white  and  a  few  red  blood-corpuscles.  As  a  result  there  is  a  decided 
lymph-stasis,  which  is  increased  by  scattered  extravasations  and  pro- 
liferation of  the  nuclei  of  the  endothelial  adventitia. 

Since  these  lymph-spaces  surround  the  ganglion-cells  and  nerve- 
fibers,  and  form  a  network  throughout  the  whole  brain,  there  is 


DISEASES  WITH  rREDOMINATING  PSYCHIC  SYMPTOMS.       583 

necessarily  a  marked  lymph-stasis  throughout  the  brain  itself,  which, 
directly  through  pressure  upon  the  nerve-elements  and  indirectly 
through  compression  upon  the  capillaries,  intorforos  witli  the  vitality 
of  these  and  may  lead  to  necrobiotic  changes. 

Since  the  perivascular  adventitial  spaces  of  the  T)rain  communi- 
cate with  the  epicerebral  spaces, — that  is,  the  lymph-spaces  of  the 
pia, — stasis  also  develops  there.  Thus  arises  the  condition  favoring 
tissue-changes  in  the  pia  (clouding,  thickening  of  the  tissue,  destruc- 
tion of  lymph-channels)  as  well  as  attachment  of  the  pia  to  the 
cortex,  as  a  result  of  which  there  is  a  backward  lymph-stasis  in  the 
brain.  In  rare  cases  the  disease  of  the  pia  is  primary  and  actually 
inflammatory  (tramnatic,  gummatous  meningitis),  and  in  such  cases 
the  lymph-stasis  develops  from  it  centrally. 

Concerning  the  significance  of  the  processes  that  take  place 
between  the  initial  neuro-paralytic  hyperemia  with  its  resulting 
lymph-stasis  and  the  final  general  atrophy,  investigators  are  by  no 
means  in  accord. 

While  the  older  authors — more  recently  Mendel,  Magnan,  Wer- 
nicke, and  others — look  upon  it  as  inflammatory,  the  idea  that  it  is  a 
simple  atrophy  and  only  secondarily  inflammatory  gains  more  and 
more  adherents  (Schule,  Binswanger). 

It  is  probable  that  this  divergence  of  opinion  depends  upon  the 
fact  that  23aralysis  is  only  a  clinical  syndrome,  and  that  various  kinds 
of  anatomic  disease-processes,  of  which  the  uniform  result  is  cerebral 
atrophy  (dementia),  cause  difl^erences  in  the  clinical  ■<i0urse,  especially 
Math  reference  to  psychic  symptoms. 

It  is  possible  that  mild  cases  that  run  their  course  without  symp- 
toms of  irritation  in  the  sense  of  maniacal  excitement,  mania,  and 
grand  delusions  are  due  to  anatomic  processes  bringing  about  primary 
atrophy,  while  the  cases  of  "classic  paralysis"  depend  upon  inflam- 
matory changes. 

The  reason  for  the  fact  that  modern  opinion  inclines  to  regard 
the  disease-process  of  general  paralysis  as  primary  and  a  simple 
atrophy  is  probably  that  the  disease  has  changed  in  character,  and 
at  the  present  time  is  seen  most  frequently  in  the  form  of  simple 
dementia. 

At  the  present  time  the  problem  for  investigators  anatomically 
and  clinically  is  to  bring  into  accord  the  actual  differences  found  ana- 
tomically and  the  various  clinical  pictures ;  but  only  cases  that  come 
to  autopsy  in  the  early  stages  of  the  disease  can  be  considered  for 
this  purpose ;  for  in  the  final  stages  of  atrophy  the  anatomic  findings 
and  the  clinical  manifestations  are  quite  in  accord. 


584  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

Moreover  it  is  improlialile  tliat  the  disease-process  of  general 
paralysis  is  exohipively  atrojiliic  or  inflammatory;  for,  when  the  proc- 
ess begins  as  a  primary  parenchymatous  atrophy,  secondary  irrita- 
tion and  proliferation  lake  place  as  a  resnlt  of  the  irritation  by  waste- 
products  of  nerve-tissue,  while,  on  the  other  hand,  a  primary  "  in- 
terstitial encephalitis^'  leads  to  secondary  atrophy  (pressure)  of  the 
nerve-elements. 

The  process  of  atrophy — primary  degeneration  analogous  to  the 
disease-process  of  tabi's  (St-liiile),  parenchymatous  and  inflammatory 
changes  (Wernicke)  like  those  of  polyneuritis— may  be  theoretically 
explained  as  due  to  early  exhaustion  as  a  result  of  excessive  func- 
tional demands  on  ganglion-cells  and  nerve-fibers  that  are  originally 
lacking  in  resistive  power;  possibly  also  as  a  result  of  toxic  influence 
(syphilitic  toxin?).  Besides  this  there  might  be  processes  in  the 
nature  of  atrophy  from  pressure  due  to  blocked  lymph-channels  in 
surrounding  areas. 

The  interstitial  encephalitis  of  cases  that  are  to  be  regarded  as 
inflammatory  may  possibly  be  due  to  the  chemic  irritation  of  specific 
material  (like  that  of  interstitial  hepatitis),  and  in  no  small  propor- 
tion to  irritation  caused  by  elements  separated  from  the  blood  and 
waste-products  of  the  nerve-tissue. 

TpiEat:\ient. — It  seems  almost  superfluous  in  a  disease  so  per- 
nicious to  speak  of  combating  its  fundamental  process.  All  patients 
afflicted  with  this  disease,  with  the  exception  of  a  few  cases  that  are 
usually  doubtful  as  regards  diagnosis,  die.  This,  however,  does  not 
absolve  us  from  the  duty  of  considering  the  treatment  of  this  grave 
cerebral  malady.  It  is  probable  that  the  discouraging  mortality  is 
due  to  the  fact  that  the  disease  is  recognized  too  late ;  that  the  patient, 
instead  of  coming  into  expert  hands  at  a  proper  time,  is  made  the 
object  of  misdirected  weakening  treatment  (bloodletting,  cold-water 
cures,  etc.),  and  is  allowed  the  time  to  destroy  himself  by  mental, 
alcoholic,  and  sexual  excesses.  Owing  to  the  circumstance  that  knowl- 
edge of  dementia  paralytica  is  becoming  more  widespread  among  gen- 
eral practitioners,  we  may  hope  for  its  early  recognition — the  first 
requisite  of  treatment. 

If  the  diagnosis  of  paralysis  has  been  made  even  with  proba- 
bility, then  all  possible  means  to  restore  a  normal  condition  of 
nutrition  and  circulation  in  the  brain  must  be  employed. 

In  the  first  place,  occupation  should  be  given  up  for  a  quiet  life  in 
the  country;  the  patient  must  be  protected  from  caloric  influences, 
and  alcohol  and  strong  tea  and  coffee  interdicted,  with  limitation  of 
smoking.    The  food  should  be  rich,  but  unirritating;  the  bowels  must 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       585 

be  cared  for,  and  lukewarm  baths  from  62°  to  72°  F.  ordered.  These 
indications  are  best  fulfilled  in  a  sanatorium,  which  affords  also 
another  important  advantage  in  the  constant  medical  attention  of  a 
specialist. 

The  frequent  and  obstinate  sleeplessness  in  the  beginning  is  best 
overcome  by  means  of  prolonged  baths  in  the  evening,  wet  packings 
for  from  one  and  a  half  to  two  hours,  and  careful  galvanization  of  the 
head  (Löwenfeld).  If  hypnotics  are  required,  then  resort  may  be 
had  to  bromides,  with  phenacetin  and  codeine,  or  eventually  trional, 
paraldehyde,  or  amylene  hydrate ;  but  chloral  hydrate  and  its  prepara- 
tions, which  are  to  be  regarded  as  decidedly  inimical  to  the  vessels, 
should  be  avoided. 

Many  physicians,  when  the  diagnosis  of  paralytic  dementia  is 
clear,  having  in  mind  the  etiologic  relation  between  it  and  syphilis, 
advise  antiluetic  treatment.  So  far  as  the  treatment  with  mercurials 
is  concerned,  I  cannot  too  emphatically  advise  that  they  be  avoided, 
for  paralysis  is  not  a  specific  disease  of  the  brain,  and  experience 
shows  that  in  this  disease  mercury  often  does  harm  and  never  does 
any  good.  Mercurial  treatment  should  be  limited  to  the  few  cases 
in  which  there  are  signs  of  lues  or  recrudescent  evidence  of  it  during 
the  beginning  of  the  paralysis.^  On  the  other  hand,  iodine  seems  to 
render  the  course  of  many  cases  of  paralysis  milder  and  more  pro- 
tracted, either  because  it  increases  metabolism,  which  may  be  helpful 
for  absorption  and  circulation  in  the  obstructed  lymph-channels, 
or  because  it  may  prevent  the  development  of  proliferative  processes 
in  the  brain.  From  1  to  1.5  grams  of  iodide  of  sodium  should  be 
given  for  months.^ 

If  congestive  symptoms  occupy  the  foreground,  ergot  (0.3  to  0.5 
gram  of  the  aqueous  extract)  may  be  exhibited  continuously  for  a 
long  time,  and  cold  to  the  head  and  nape  of  the  neck,  and  flowing  foot- 
baths are  indicated. 

If  the  disease  has  reached  its  full  development,  the  important 
question  arises  whether  and  when  to  send  the  patient  to  an  asylum. 
Under  all  circumstances  he  requires  the  most  careful  nursing  and 
watching. 

'The  depressed  and  hypochondriac  paralytics  belong  without  ex- 
ception in  asylums  for  the  insane,  owing  to  the  danger  of  suicide 


^  There  is  increasing  evidence  that  intramuscular  injections  of  calomel 
have  a  decided  influence  to  ameliorate  the  symptoms  of  tabes  and  dementia 
paralytica. — Teanslator. 

^  Occasional  interruption  of  the  iodides  is  advisable  when  prolonged  ad- 
ministration is  indicated." — Translator, 


586  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

and  the  almost  constant  refusal  of  food,  which  is  very  obstinate. 
The  same  is  necessary  in  cases  of  classic  paralysis  with  grand  delu- 
sions, witli  or  witho\it  nuiniacal  excitement,  on  account  of  the  danger 
to  self  and  dHuts,  and  tlio  financial  interests  of  the  family,  and  also 
because  of  the  possibility  of  a  sudden  outbreak  of  furious  numia. 

The  simple  paralytic  is  also  dangerous  to  others  and  himself,  on 
account  of  disturbance  of  consciousness  and  dementia.  If  the  means 
permit  care  and  watching  in  private,  then  the  patient's  family  may 
be  spared  the  sorrow  of  commitment  to  an  institution. 

During  remission  of  the  malady  and  its  final  stage  such  patients 
as  luive  a  home  and  devoted  relations  are  mur]i  more  suitable  for 
family  care. 

Concerning  remedies  directed  against  the  disease-process  during 
the  stage  of  its  activit}-,  very  little  of  a  satisfactory  nature  is  to  be 
said. 

Since  in  rare  cases,  following  phlegmons,  severe  suppuration, 
and  facial  erysipelas,  recovery  from  paralysis  has  been  observed,  at- 
tempts have  been  made  by  inducing  suppuration  artificially  and  the 
application  of  powerful  irritants  to  the  shaved  head  (moxa,  hair- 
ropes,  fontanelles,  unguentum  Authenriethi),  to  imitate  N^ature, 
but  without  success.  Treatment  should  be  limited  to  the  internal 
administration  of  preparations  of  iodine — in  case  of  necessity,  com- 
bined with  ergot.  In  cases  of  simple  exhaustion-paralysis,  tonics — 
especially  syrup  of  hypophosphites  (Fellows) — are  of  some  use. 

If  in  this  stage  of  the  disease  the  indicatio  morbi  does  not  suf- 
fice, still  there  are  many  symptomatic  indications  which  demand 
medical  activity.  For  the  most  part,  these  consist  of  sleeplessness 
and  states  of  excitement.  Sleeplessness  is  to  be  combated  by  pro- 
longed baths,  trional,  paraldehyde,  and  amylene  hydrate.  At  times 
chloral  hydrate,  with  or  without  morphine,  or  an  injection  of  du- 
boisine  sulphate  (0.001  gram)  may  be  tried.  There  are  numerous 
cases  in  which  the  insomnia  is  temporarily  rofi'actory  to  all  these 
remedies  in  heroic  doses. 

The  states  of  excitement  are  partly  delirious,  partly  angry  out- 
breaks of  fury,  partly  states  of  psychomotor  excitement  accompanied 
by  violent  congestion,  which  may  reach  the  intensity  of  furious  ex- 
citement. Trional  or  sulphonal  in  broken  doses  is  useful  to  over- 
come delirious  states.  The  wjive  of  the  affect  is  smoothed  by  mor- 
phine (0.01  to  0.025  gram)  subcutaneously  administered. 

In  states  of  congestive  excitement  injections  of  morphine  are 
also  useful,  probably  because  of  its  stimulating  effect  upon  the  ves- 
sels and  its  influence  to  overcome  vaso-paralytic  hyperemia.     Where 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       587 

congestion  is  violent^,  preparations  of  ergotino  (Wernicli,  Bonjcan, 
Bombelon)  have  often  a  remarkable  and  prompt  effect.  It  is  best 
given  as  an  injection  (0.3  to  1  gram)  diluted  in  sterilized  water. 
Prolonged  lukewarm  baths  with  the  ice-cap  and  preparations  of  digi- 
talis may  have  a  supporting  influence. 

In  case  of  violent  fury  with  destructive  tendencies,  hyoscine 
hydrochlorate  or  duboisine  sulphate  in  doses  of  0.001  gram  subcu- 
taneously,  and  0.002  gram  by  mouth  as  a  maximum  dose,  may  be  tried. 
They  are  also  very  suitable  to  bring  about  momentary  psychomotor 
rest  and  thus  to  facilitate  the  transportation  of  the  patient  to  an 
asylum . 

Important  episodic  phases  are  the  paralytic  and  epileptiform 
seizures.  If  the  paralytic  attacks  be  accompanied  by  violent  conges- 
tion, one  or  two  leeches  behind  the  opposite  ear  and  the  ice-cap  are 
indicated. 

In  order  to  excite  the  circulation  and  metabolism  in  the  brain 
and  to  overcome  the  regional  exudation  or  transudation  (edema) 
which  is  probably  the  cause  of  the  attack,  decided  diaphoresis  and 
depletion  through  the  skin  (packing),  and  also  calomel,  0.5  to  0.7 
gram,  which  causes  a  decided  diuresis,  are  useful. 

In  cases  of  epileptiform  attacks,  possible  retention  of  urine  or 
eoprostasis.  as  causes  should  be  looked  for  and  overcome.  If  the  cause 
of  the  attack,  which  is  often  dangerous  to  life,  is  central,  then  the 
cortex  must  be  rendered  insensitive  to  the  causal  and  continued  irri- 
tation. This  indication  is  most  quickly  and  surely  fulfilled  by  enemas 
of  chloral  hydrate  (2.5  to  3.0  grams).  While  the  patient  continues  in 
the  seizure,  liquid  food  should  not  be  poured  into  the  mouth,  owing 
to  the  danger  of  choking  and  eventual  pneimionia  from  entrance  of 
food  into  the  lungs. 

In  the  final  stages  of  the  disease,  owing  to  the  filthiness  of  the 
patients,  it  is  necessary  to  carry  out  the  strictest  cleanliness,  to  give 
attention  to  the  retention  of  urine  and  its  consequences,  as  well  as  to 
decubitus,  and  to  keep  the  patient  warmly  covered.  Food  must  be 
carefully  given  (only  small  mouthfuls  of  soft  food)  to  prevent  the 
patient's  choking  or  the  entrance  of  particles  of  food  into  the  air- 
passages,  with  the  induction  of  pneumonia  or  gangrene  of  the  luno-s. 

Case  72. — Acute  paralysis. 

H.,  pensioned  officer,  aged  41,  was  admitted  to  the  asylum  March  14, 
"1878.  He  had  passed  through  the  campaigns  of  1859  and  1866,  and  duiüng  the 
first  suflfered  with  severe  intermittent  fever,  and  in  the  last  had  had  a  fall 
from  his  horse.  In  1864  luetic  infection,  with  several  subsequent  secondary 
conditions  which  finally  yielded  to  energetic  mercurial  treatment.    The  patient 


588  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

was  not  remarkable  mentally;  was  self-willed  and  irritable.  Until  a  few  j'eara 
before  he  had  committed  great  excesses  in  venery.  There  was  said  to  have 
been  no  insanitj'  in  his  family.  For  two  months  he  had  been  self-assertive  and 
impossible,  spoke  often  foolishly  about  politics,  and  went  out  in  society. 

A  few  daj's  before  his  admission  H.  became  congested,  sleepless,  restless, 
excited,  and  made  visits  in  houses  and  business  places  where  he  made  remark- 
able and  unseemly  speeches.  He  forced  his  way  into  the  apartment  of  a 
prima  donna  of  tiie  opera,  and  his  conduct  was  impolite.  He  made  her  a 
declaration  of  love  and  wished  to  be  married  immediately. 

On  admission  he  was  in  mania,  having  the  greatest  feeling  of  well-being, 
and  immeasurable  delusions  of  grandeur  (he  is  the  finest  singer,  the  most 
intimate  friend  of  the  emperor,  gives  everyone  around  him  a  half-million  in 
order  to  banish  poverty;  he  awaits  his  bride,  the  prima  donna,  etc.).  Stormy 
effort  to  escape,  which  is  overcome  by  slight  attention.  The  patient  is  con- 
gested, sleepless,  and  at  times  has  spasmodic  hesitating  speech. 

JMarch  21st,  the  patient  becomes  quiet,  remains  in  bed,  but  his  conscious- 
ness is  much  interfered  with.  He  laughs  constantly  and  plays  shamelessly 
with  his  genitals.  In  the  beginning  of  Älay  renewed  and  continued  excite- 
ment, which  becomes  more  and  more  truly  impulsive,  objectless  activity.  He 
jumps,  drapes  himself  fantastically  in  his  room,  tears  everything  that  falls  in 
his  hands,  and  forces  everything  into  his  mouth.  Continued  profound  disturb- 
ance of  consciousness  with  great  confusion.  What  the  patient  says  are  only 
senseless  fragments  of  sentences  and  incomprehensible  mixtures  of  words. 
Here  and  there  are  signs  of  remains  of  his  grand  delusions  without  emotional 
coloring.  All  efforts  to  quiet  him  are  unsuccessfid.  The  motor  impulse  in- 
creases to  continued  smearing  and  eating  of  dirt  and  feces.  The  patient 
becomes  violent  when  an  effort  is  made  to  prevent  this.  It  frequently  hap- 
pened that  he  ate  sand  and  feces  and  smeared  his  hair  and  face.  Mechanical 
restraint  prevented,  in  a  measure,  these  impulses.  From  the  few  words  he 
was  able  to  speak,  it  was  evident  that  the  patient  took  the  sand  for  expensive 
cliocolate.  Grave  panaris  in  the  middle  of  September.  In  the  beginning  of 
October,  diarrheas  difficult  to  check;  rapid,  increasing  marasmus;  decubitiis. 
Death  in  collapse,  October  19th. 

Autopsy:  Cranium  symmetric,  not  thickened;  sutures  evident.  Dura 
attached  to  the  skull  on  its  inner  surface  without  changes.  Pia  and  arachnoid 
over  the  frontal  lobe  and  central  convolutions,  especially  along  the  vessels, 
clouded.  The  pia  is  closely  attached  to  the  cortex  and  cannot  be  removed 
without  bringing  away  portions  of  cerebral  substance.  The  cortex  is  brown- 
ish, not  showing  the  layers  clearly,  and  somewhat  thinned  and  anemic  over 
the  frontal  lobes.  The  radiations  of  Gratiolet  of  the  frontal  and  central  con- 
volutions decidedly  reduced.  Hydrops  of  the  ventricles.  Brain  edematous,  but 
of  firm  consistence.  No  trace  of  syphilis  in  the  vegetative  organs.  Chronic 
gastro-intestinal  catarrh. 

Case  73. — Classic  paralysis.    Subaciite  course. 

S.,  physician,  aged  40,  of  healthy  parents.  Father's  sister  was  insane. 
The  patient  had  no  severe  diseases,  was  never  infected  with  syphilis,  but  as  a 
voung  man  was  a  good  liver  and  fast;  since  his  marriage  at  the  age  of  34 
had  been  of  good  morals.  He  lived  in  happy  marriage  and  had  three  healthy 
children;    was  much  overworked  in  his  profession  as  a  country  physician.    In 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       589 

1869  he  had  gastric  fever,  and  during  his  convalescence  had  to  take  up  his 
work  again,  and  complained  often  of  fatigue  a,nd  his  desire  for  repose. 

In  the  Legiiming  of  1870  his  manner  and  character  became  quite  different. 
He  was  distracted,  forgetful,  negligent  in  his  practice,  and  seemed  emotional 
and  irritable.  Toward  the  end  of  February  he  became  restless,  unsteady, 
hesitating  in  speech  and  act,  and  traveled  about  without  purpose;  and  he 
made  purchases  that  were  not  in  accord  with  his  relations  and  needs.  He 
wished  to  embellish  his  house  and  property  and  change  everything.  He  him- 
self dug  up  a  vineyard  because  he  wished  to  make  a  garden  where  it  was, 
destroyed,  the  vines,  cut  off  the  branches  of  his  fruit-trees,  and  forgot  in  one 
hour  what  he  had  undertake«  the  hour  before.  He  forgot  his  family  and  his 
profession,  and  had  no  idea  of  time  and  place.  He  lost  insight  into  his  per- 
verted acts,  and  was  threatening  when  his  relatives  called  his  attention  to  it 
and  when  he  was  asked  to  control  liis  senseless  activity.  Of  late  the  patient 
was  almost,  sleepless,  his  speech  slow,  his  walk  uncertain,  and  his  expression 
tired.  On  account  of  his  restlessness  and'  his  increasing  agitation,  he  was 
brought  to  tlie  asylum  toward  the  end  of  the  month  of  May,  1870.  He  had  to 
be  brought  by  force.  In  his  new  surroundings  he  soon  felt  as  if  he  were  at 
home.  His  fatigued  features,  relaxed  attitiule,  troubled  intelligence,  the  un- 
equal pupils,  the  marked  tremor  of  the  tongue,  indicate  a  grave  organic  malady 
of  the  brain.  The  vegetative  functions  are  not  disturbed;  temperature  is 
normal;    pulse  slow,  from  70  to  80. 

The  patient  is  in  great  psychic  and  motor  excitement,  talkative,  and  with 
flight  of  ideas.  He  is  full  of  senseless  projects,  but  forgets  from  hour  to  hour 
what  he  has  undertaken.  He  wishes  to  go  to  Italy,  the  Orient,  America,  but 
with  slight  persuasion  his  journeys  are  postponed.  In  one  breath  he  asks  for 
wine,  cigars,  women,  and  at  times  makes  angry  attacks  upon  those  around 
him  when  his  desires  and  plans  are  not  immediately  complied  with;  but  one 
project  is  chased  away  by  another.  The  patient  is  sleepless  and  does  not  stay 
in  bed.  In  the  very  first  days  after  his  admission  he  develops  grand  delusions. 
He  invites  a  million  persons  on  his  oriental  journey,  writes  hundreds  of  tele- 
grams to  potentates  and  learned  men,  orders  leviathans  for  his  ocean  journey, 
calls  a  meeting  of  twenty-eight  million  Germans,  and  intends  to  build  a  city 
of  a  million.  The  patient  has  no  idea  of  time  and  place,  and  consciousness  is 
profoundly  disturbed.  At  dinner  he  empties  his  salad  in  his  soup.  Increasing 
excitement,  impulsive  forced  thought,  and  rapid  speech.  His  grand  delusions 
become  more  and  more  monstrous  and  impossible.  The  patient  lives  in  his 
enthusiasm — his  city  of  a  million  is  already  built;  every  inhabitant  will  have 
the  superb  head  of  Goethe.  He  convokes  all  the  planets  of  the  universe, 
makes  the  earth  into  a  mine  of  diamonds.  He  pays  for  his  gigantic  projects 
with  bank-notes  that  he  makes  with  his  rotary  machine,  and  he  has  as  many 
of  them  as  he  desires.  He  will  soon  be  finished  with  the  earth.  He  already 
has  the  north  pole,  and  he  is  about  to  build  a  central  sea  with  infinite  rapid- 
ity. He  has  brought  down  the  sun  and  made  it  a  block  of  gold.  He  has 
brought  it  down  because  in  the  sun  there  is  no  aqua  regia  to  dissolve  it.  He 
has  brought  down  the  planets  and  made  new  ones  of  gold,  and  has  attached 
them  at  a  thousand  feet  from  the  earth.  He  bursts  the  crust  of  the  earth 
with  nitroglycerin  to  the  depth  of  one  hundred  feet  and  fills  it  with  diamonds. 

In  June  the  state  of  excitement  quickly  subsides  and  leaves  a  state  of 
profound  mental  weakness,  in  which  there  are  only  now  and  then  silly  delu- 


590  SPECIAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

sions  of  grandeur  (he  has  a  waistcoat  bedecked  with  diamonds,  sacks  of  dia- 
monds in  the  cellar,  his  wife  has  a  diamond  corset,  etc.).  The  pa-ticnt  has 
numerous  errors  of  memory — he  was  here  months  before.  A  picture  of  Rome, 
a  place  where  he  had  never  been,  awakes  in  him  the  supposed  memory  of  that 
city  in  all  possible  details.  The  patient  is  not  orientated  in  time.  He  takes 
dinner  for  supi>er,  has  no  further  interest  in  his  physical  needs,  and  docs  not 
ask  about  his  profession  and  family.  Awkwardness  of  movement;  awkward, 
unsteady  gait;  unequal  pupils,  tirst  one  then  the  otlicr  the  larger;  drooping, 
relaxed,  tremulous  features;    and  increasing  stumbling  on  syllables. 

In  November,  without  any  observable  cause,  rapid  psychic  deterioration. 
The  patient  became  confused,  demented,  and  at  times  even  stuporous.  He  is 
in  a  cloudy  state,  has  to  be  made  to  eat,  and  becomes  unclean.  Ihe  speech  at 
times  becomes  quite  incomprehensible  (aphasia,  stumbling  on  syllables),  walks 
wilh  feet  wide  apart,  gait  uncertain,  and  tiie  body  inclines  to  the  left  side. 
Now  and  then  traces  of  grand  delusions   (masses  of  gold,  diamonds). 

From  December  on  apathetic  dementia;  loss  of  ideas  of  movements; 
purposeless,  awkward  picking  at  his  clothing. 

From  Janiiary,  1871,  on  there  is  marasmus,  rapid  deterioration,  the  hair 
becomes  gray,  pulse  extremely  slow,  temperature  subnormal.  The  patient 
keeps  his  bed  and  is  no  longer  able  to  stand  on  his  feet.  He  must  be  fed,  for 
he  no  longer  perceives  the  food  and  has  not  the  necessary  ideas  of  movement. 

In  tha  middle  of  March,  difficult  respiration  and  dysphagia  appear. 

March  lOth  the  patient  died  of  pneumonia. 

Autopsy:  Hyperostosis  of  the  skull,  sutures  obliterated  in  great  part. 
External  hydroceplialus;  milky  clouding  and  thickening  of  the  soft  mem- 
branes over  the  anterior  and  parietal  lobes,  with  traces  of  the  same  condition 
at  the  base.  The  membranes  cannot  be  removed  from  the  cortex  without 
bringing  away  portions  of  it,  and  are  edematous.  Frontal,  parietal,  and 
temporal  convolutions  atrophic,  especially  the  central  convolutions.  Cortex 
yellowish,  external  layer  swollen,  markings  retained.  ^\hite  substance 
anemic,  edematovis,  and  increased  in  consistency. 

Ventricles  dilated,  the  ependyma  granular,  hydrocephalus  internus; 
eray  degeneration  of  the  posterior  columns  of  the  cord.  With  the  exception 
of  the  apex,  the  left  lung  is  in  a  state  of  gray  hepatization.  Hypostatic  con- 
dition of  the  right  lung.     Heart  fatty.     Aorta  very  atheromatous. 

Case  T4. — Hypochondriac  form  of  paralysis.  After  a  remission 
it  takes  on  the  classic  form.  After  another  profound  remission,  re- 
currence of  the  hypochondriac  form. 

S.,  aged  31,  brewer,  said  to  be  without  hereditary  taint,  always  of  ec- 
centric, irritable  character.  In  1873  he  went  to  London  to  perfect  himself  in 
his  calling.  There  he  gave  himself  up  to  drink  and  sexual  excesses,  and, 
against  the  expressed  will  of  his  parents,  riiarried.  As  a  result  of  this  his 
relations  with  his_ family  were  estranged.  They  gave  him  no  support,  and  in 
this  painful  situation  he  gave  himself  up  to  extreme  excesses  in  drink.  About 
five  months  ago  he  became  sleepless,  excited,  often  had  vertigo,  headache,  con- 
"■estion,  and  is  said  to  have  had,  at  times,  grand  delusions.  He  became 
irritable,  depressed,  forgetful,  and  distracted.  When  two  months  ago  he 
returned  to  his  parents'  house  he  was  w^eak  mentally,  physically  reduced,  his 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       59I 

expression  was  changed,  painfully  depressed,  and  thonglifc  he  was  in  poverty 
and  incurable. 

It  was  remarked  on  his  return  that  his  gait  and  speech  were  uncertain. 
A  hypochondriac-melancholic  disease-picture  developed  more  and  more  clearly, 
and  when  the  patient  began  to  refuse  food  it  was  necessary  to  send  him  to  the 
asylum,  October  18,  1875. 

On  admission  the  patient  Avas  profoundly  disturbed,  dumb,  anxious,  with 
increased,  superficial  respiration,  very  slow  pulse,  widespread  intercostal 
neuralgia,  tremor  of  the  tongue,  shuffling,  slightly  staggering  gait,  salivation, 
and  retention  of  urine.  After  a  few  days  the  patient  began  to  speak;  speech 
was  not  disturbed,  except  that  it  was  noticeably  nasal.  There  was  gastric 
and  nasal  catarrh,  with  great  secretion  of  mucus.  Constipation,  great  anemia, 
and  decided  loss  of  weight.  The  patient  had  to  be  forcibly  fed.  The  reasons 
for  the  refusal  of  food  were  numerous  hypochondriac  feelings  and  delusions. 

There  is  a  feeling  of  pressure  in  his  abdomen  reaching  up  to  the  breast; 
his  throat  is  stopped  up;  his  abdomen  is  constantly  vibrating.  The  urine 
does  not  get  any  better.  He  suffers  with  stoppage  of  water;  the  whole  body 
is  out  of  order.  Digestion  is  gone,  his  body  is  full,  and  food  is  being  forced 
into  him  and  does  not  leave  him.  He  asks  whether  it  will  not  be  necessary  to 
cut  open  his  abdomen.  It  would  be  better  to  give  him  prussic  acid.  All  the 
force  of  his  body  is  gone.  He  is  infected  with  vermin,  and  people  always  said 
he  had  a  chancre. 

Pus  comes  out  of  his  throat;  he  is  full  of  pus;  his  brain  is  soaked  in 
urine.  Along  with  the  emotion  accompanying  these  ideas  there  was  still  great 
mental  weakness.  Simple  threats  were  sufficient  to  induce  the  patient  to  take 
food.     Frequently  there  was  inability  to  pass  urine. 

The  end  of  February,  1876,  the  hypochondriac  delirium  disappeared  with 
improvement  in  the  gastric  catarrh,  and  there  was  a  decided  remission; 
but  the  continuance  of  the  mental  weakness,  the  motor  disturbances,  and  the 
salivation  indicated  the  gravity  of  the  disease.  The  middle  of  April  there  Avas 
hesitating  speech  and  tAvitching  of  the  facial  muscles  in  expression  and  articu- 
lation. 

April  18th  the  patient  Avas  foimd  in  a  state  of  profoimd  disturbance  of 
consciousness,  Avith  signs  of  violent  congestion.  In  this  stupid  state  he  re- 
mained until  the  26th,  when  a  state  of  maniacal  excitement  came  on.  The 
patient  was  restless,  slept  little,  talked  confusedly,  expressed  desultory  delu- 
sions of  grandeur,  had  the  impulse  to  collect  everything,  great  disturbance  of 
consciousness,  marked  stumbling  on  syllables,  staggering  gait,  and  frequently 
vascular  paralysis  in  the  face.  With  violent  congestion  in  May,  there  was 
temporarily  furious  mania,  Avith  tearing,  destructiveness,  smearing,  and  then 
the  excitement  subsided  to  the  level  of  maniacal  exaltation  Avith  grand  delu- 
sions. The  patient  talked  about  a  rich  bride,  a  magnificent  marriage,  gigantic 
brcAveries  Avhich  he  Avould  build.  The  middle  of  August,  in  the  midst  of  this 
picture  of  classic  paralysis,  there  was  a  second  marked  remission.  The  patient 
recognized  his  condition  and  gave  as  the  causes  of  his  disease  those  already 
mentioned.  He  corresponded  with  his  relatives  and  presented  no  particular 
symptoms  aside  from  mental  weakness,  disturbance  of  speech,  and  frequent 
vascular  paralysis  in  the  face. 

Thus  he  continued  until  the  beginning  of  January,  1877,  Avhen  there  was 
a  remarkable   recurrence   of   the   hypochondriac-melancholic   picture,   accom- 


503  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

panied  by  recrudescence  of  the  gastric  and  pharyngeal  catarrh.  This  con- 
tinued until  the  end  in  profound  dementia.  The  delusions  were  on  this  occa- 
sion still  more  monstrous  and  demented  than  at  first.  The  patient  stated 
that  he  had  no  stomach;  that  he  was  absolutely  stopped  up;  that  his  breath- 
ing and  pulse  were  arrested;  that  throat  and  intestines  were  obstructed,  and 
that  his  bowels  had  never  moved;  that  his  body  was  filled  with  pus,  etc. 
Now  and  then  micromaniaeal  ideas  were  expressed;  as,  for  example,  that  he 
was  a  little  boy  of  16,  etc.  At  first  the  patient  would  not  eat.  and  had  painful 
emotional  reaction  to  his  feelings  and  delusions.  With  rapid  progress  of  the 
dementia  he  became,  in  spite  of  his  hypochondriac  complaints,  gluttonous  and 
without  emotional  feeling. 

The  motor  and  vasomotor  disturbances  constantly  increased.  The 
speech  became  almost  incomprehensible  at  times,  owing  to  great  stumbling 
on  syllable.*  and  labial  ataxia,  the  gait  unsteady  and  staggering,  the  movements 
of  the  hands  awkward.  The  left  pupil  became  dilated.  There  was  often  re- 
tention of  urine.  Attacks  of  vertigo,  aphasic  symptoms,  and  attacks  of  con- 
gestion were  observed.  The  pulse  became  extremely  slow,  the  extremities  cool 
and  slightly  cyanotic.  The  feet  became  edematous  if  he  stood  on  them  for 
any  length  of  time. 

In  the  course  of  the  year  1879  there  was  decided  loss  in  general  nutrition. 
In  the  beginning  of  September  there  wa«  profuse  diarrhea  with  fever,  which 
soon  proved  to  be  uncontrollable.  The  patient  refused  food,  and  along  with 
the  remains  of  his  hypochondriac-nihilistic  delirium  (no  teeth,  no  abdomen), 
during  his  la.st  days  he  had  inanition-deUria,  and  died  in  profound  marasmus 
September  17,  1879. 

Autopsy:  Skull  and  dura  normal.  Decided  increase  of  serum  in  the 
arachnoid  space.  Pia  over  frontal  and  parietal  lobes  diffusely  whit«  and 
thickened,  edematous,  easily  separated  from  the  cortex.  The  convolutions  of 
the  forebrain  deeidedly  narrowed  and  below  the  general  level.  Ventricles  de- 
cidedly dilated.  Ependyma  markedly  granular.  Cortex  much  thinned,  with- 
out markings  of  layers,  and  of  yellowish-gray  color.  The  brain  anemic, 
edematous,  and  of  firm  consistence.  Vessels  and  nenes  at  the  base  without 
alterations. 

Case  75. — rrimary  progressive  dementia  paralytica  following 
mental  overwork. 

S.,  aged  40,  married,  was  admitted  to  the  asylum  November  8,  1877.  His 
father  died  of  apoplexy.  A  sister  of  his  mother  was  insane.  A  brother  of 
the  patient's  died  of  suicide  in  an  attack  of  insanity. 

The  patient  was  a  nervous,  irritable  man,  afflicted  with  frequent  head- 
aches, not  very  bright,  but  very  industrious,  with  a  strong  sense  of  duty  and 
given  to  no  excesses. 

Three  years  ago,  during  eleven  months,  he  was  very  much  overworked. 
Following  this  there  were  occasional  headaches  and  attacks  of  congestion  and 
dizziness.  He,  who  formerly  had  written  with  great  ease,  could  now  perform 
the  slightest  work  only  with  great  difficulty.  "Work  exhausted  him  mentally; 
he  became  confused  and  his  style  became  heavy.  In  spite  of  a  sojourn  in  the 
country  and  the  greatest  care,  the  mental  deficiency  made  rapid  progress.  In 
his  work  he  tried  to  find  the  correct  expression,  but  never  could.  On  May 
22,  1877,  after  the  midday  meal,  he  had  an  apoplectic  attack,  remained  several 


DISEASES  WITT!  PflKnOMIN-ATfXr;  P.SYCfllC  SYMPTOMS.       593 

hours  unconscious  with  congestive  symptoms,  was  temporarily  confused  and 
excited,  but  quickly  recovered  without  signs  of  paralysis;  but  since  this  he 
had  shown  decided  loss  of  memory  and  become  absolutely  incapable  of  work. 

After  staying  three  months  at  a  cold-water  cure,  disturbance  of  speech 
came  on,  and  mental  weakness  was  still  more  marked.  Toward  the  end  of 
October  the  patient  felt  his  left  ringfinger  to  Ikj  ice-cold,  and  this  feeling 
spread  over  the  Whole  forearm.  Motility  was  not  disturbed,  but  sensibility 
was  greatly  reduced.  This  trouble  (vascula.r  spasm?)  o<;currcd  in  attacks 
several  times,  lasting  as  long  as  a  quarter  of  an  hour. 

On  the  2d  of  June  there  was  a  congestive  state  of  excitement,  in  which 
his  consciousness  was  profoundly  disturbed.  He  became  delirious,  raved,  but 
after  a  ievr  hours  came  to  himself  again  and  was  quiet. 

On  the  7th  there  was  another  attack  of  excitement,  v/hich  caused  him  to 
be  brought  to  the  asylum.  The  patient  did  not  recognize  his  situation.  He 
thought  that  his  nerves  were  destroyed,  and  he  was  in  danger  of  going  insane. 
His  memory  was  very  defective,  his  consciousness  clouded ;  glance  and  expres- 
sion indicated  advanced  dementia;  his  speech  was  heavy,  and  often  he  could 
not  find  the  right  word,  and  was  painfully  impressed  by  this.  Articulation 
was  much  disturbed — some  syllables  were  swallowed,  others  were  tinusualiy 
accented,  as  if  spasmodically  pronounced.  With  the  articulatory  movements 
there  was  lively  twitching  of  the  facial  muscles.  Myosis  in  both  eyes.  The 
tin-jr  movements  of  the  hands  were  uncertain;  the  handwriting  grotesque, 
unequal;  the  gait  stiff,  wooden,  and  slightly  staggering  when  he  turned 
around.  No  disturbances  of  sensibility.  Pulse  verv'  slow.  The  ophthal- 
moscope showed  no  changes  in  the  fundus  except  venous  stasis.  The  vege- 
tative organs  were  without  findings,  except  for  hemorrhoids  and  constipation. 

The  dementia  and  disturbance  of  consciousness  constantly  progressed. 
The  patient  is  dreamy,  thinks  at  one  time  he  is  at  home,  at  another  at  the 
sanitarium.  His  memory  is  extremely  defective.  Late  impressions  are  no 
longer  retained.  Old  and  new  impressions  are  mixed  together  without  order. 
Communication  of  thought  is  made  difficult  by  aphasic  and  paraphasic  symp- 
toms. The  patient  tries  all  day  long  without  success  to  write,  and  is  thus 
exhausted  and  fatigued.  Now  and  then,  in  this  state  of  cloudy  consciousness, 
there  are  fragmentary  delusions  of  grandeur  without  further  elaboration  (he 
becomes  a  general,  is  decorated,  must  go  to  the  emperor),  and  also  those  of 
persecution  (he  has  committed  adulterv',  and  must  appear  before  a  court- 
martial,  etc.).  The  disturbance  of  speech  is  variable — in  general,  however, 
progressive.  His  attitude  is  more  and  more  relaxed,  his  gait  more  spastic  and 
uncertain.  Xow  and  then  there  are  attacks  of  vertigo  and  congestion  with 
decided  vascular  paralysis,  fluxion,  incapability  of  speech,  and  psychic  excite- 
ment manifested  in  wandering  about  and  futile  efforts  to  escape.  In  May, 
1878,  nine  epileptiform  attacks.  In  August  an  apoplectiform  seizure,  after 
which  the  dementia  and  disturbance  of  speech  were  decidedly  increased  and 
remained  so. 

In  the  course  of  the  winter  of  1878-79  there  were  now  and  then,  with 
considerable  congestion,  attacks  of  joyful  excitement  lasting  as  long  as  ten 
days,  limited  to  optimistic  ideas,  impulsive  thought,  and  motor  unrest. 

In  February  and  March,  1879,  there  were  repeated  epileptiform  seizures. 

On  May  20th,  after  the  patient  had  gone  about  all  day  as  if  lost,  at  7 
o'clock  in  the  evening  there  were  frequent  epileptiform  seizures.    At  11  o'clock 

33 


594:  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

in  evening  the  whole  left  side  of  the  body  was  paralyzed,  while  on  the  right 
side  the  spasm  continued.  The  patient  lay  in  sopor,  with  stertorous  breath- 
ing, but  the  temperature  did  not  rise  above  38°  C.  At  6  o'clock  in  the  morning 
on  the  21st,  death. 

Autopsy:  Hyperostosis  of  the  cranium.  Dura  normal.  The  soft  mem- 
branes clouded  and  thickened  along  the  large  vessels  over  the  convexity.  The 
vessels  of  the  pia  very  tortuous,  and  in  places  much  injected.  The  sinuses  at 
the  base  overfilled  with  blood.  The  pia  hypcremic,  edematous;  over  the  sec- 
ond and  third  left  frontal  convolutions  it  can  be  removed  only  by  bringing 
away  portions  of  the  cortex.  The  convolutions  are  of  coarse  morphologj'. 
In  the  frontal  and  parietal  lobes  they  are  narrowed,  and  in  certain  places 
below  the  general  level.  The  cortex  is  reddish  gray.  In  the  gray  as  well  as 
in  the  white  substance  the  lumina  of  the  vessels  are  very  prominent.  The  cut 
surface  everywhere  has  a  watery,  shiny  appearance,  especially  pronounced  in 
the  right  hemisphere. 


CHAPTER  III. 
Cerebral  Syphilis. 

The  fact  that  syphilitic  anemia  (as  a  result  of  syphilitic  disease 
of  the  blood-forming  organs,  chlorosis)  is  capable  of  inducing  psy- 
choneuroses  which  differ  in  no  way  from  those  due  to  other  causes 
has  already  been  referred  to  in  the  discussion  of  etiology  (page  181) 
Besides  such  cases,  however,  syphilis,  as  a  result  of  tissue-changes  in 
the  brain  and  its  membranes,  may  lead  to  brain  affections,  which, 
owing  to  their  diffuse  character,  cause  mental  symptoms  to  predomi- 
nate in  the  disease-picture,  and  thus  they  fall  in  the  domain  of 
psychiatry. 

The  occurrence  of  such  luetic  cerebral  affections  is  favored  when 
the  brain  is  weakened  by  predisposition,  overwork,  or  excesses  of  any 
kind.  In  such  cases  the  localization  of  the  affection  in  the  brain  may 
take  place  very  early  after  the  primary  infection.  In  other  cases 
this  occurs  in  sj^Dhilitics,  or  in  those  that  have  been  syphilitic,  only 
after  many  years,  indeed,  even  after  decades,  as  a  result  of  some  ex- 
citing cause — for  example,  trauma  capitis.  In  the  first  instance  the 
luetic  localization  is  frequently  accompanied  by  syphilitic  disease  of 
other  organs ;  in  the  second,  it  is  usually  an  independent  disease. 

The  cerebral  changes  lying  at  the  foundation  of  cerebral  syphilis  are 
extremely  numerous  in  localization  and  character.  Along  with  simple  scle- 
rotic, suppurating,  hyperemic,  gummatous  periostitis,  giunmatous  osteomj'e- 
litis,  and  Virchow's  inflammatory  atrophy  (caries  sicca)  in  the  cranial  bones, 
there  are  simple  inflammatory  and  specific  processes  aflfecting  the  meninges, 
the  substance  of  the  brain,  and  the  cerebral  arteries. 

The  changes  observed  in  the  dura  are  pachymeningitis  externa,  partly 
interna,  partly  gimimatous  meningitis,  which  is  most  frequent  between  the 


DISEASES  WITH  PREDOMINATING  PSYCIITC  SYMPTOMS.       505 

folds  of  this  membrane  and  terminates  in  caseous  tumors.  Specific  processes 
(syphiloma)  are  more  frequent  in  the  subarachnoid  space,  which  Heubner 
recognized  as  reddish  white  or  grayish  red,  or  gray  moist  masses  of  gelatinous 
consistence.  These  are  circumscribed  masses,  never  distinctly  limited  from  the 
cerebral  substance,  which  is  in  a  state  of  white  or  red  softening,  and  these 
masses  end  probably  in  caseous  degeneration  (yellow  masses).  Over  the  con- 
vexity they  attach  the  membranes  together  and  to  the  cerebral  surface  (soft- 
ening). At  the  base  of  the  brain  the  membranes  are  frequently  untouched  by 
the  process,  which  appears  to  be  rather  a  gray,  gelatinous  infiltration,  the 
appearance  and  extent  of  which  cause  it  to  resemble  tuberculous  meningitis. 

If  absorption  of  the  syphilitic  masses  occurs,  then  the  membranes  present 
a  scar.  Syphilitic  independent  tumors  in  the  brain  are  infrequent.  They 
occur  only  in  connection  with  those  of  the  membranes,  as  a  rule.  Diffuse 
encephalitic  processes  are  more  frequent  (Virchow,  Schule).  The  circulation 
and  nutrition  of  the  brain  suffer  further  important  injury  as  a  result  of  the 
endarteritis  and  frequent  disease  of  the  arteries  of  the  base  described  by 
Heubner,  as  a  result  of  which  they  become  blocked  (especially  the  Sylvian 
artery  and  that  of  the  corpus  callosum).  Since  these  are  end-arteries,  the 
areas  supplied  by  them  (especially  the  lenticular  nucleus  and  caudate  nucleus) 
easily  undergo  softening.  There  may  be  also  changes  in  the  cranial  nerves  at 
the  base  due  to  sim|>le  inflammatory  or  specific  processes  (retracting  exudates, 
syphiloma). 

Owing  to  tlie  variation  of  the  anatomic  processes  and  their 
localization,  we  can  understand  the  variations  in  the  clinical  picture 
of  cerehral  syphilis,  in  which  diffuse,  as  well  as  focal  symptoms,  may 
occur  without  order  or  grouping.  Very  rarely  the  disease-picture 
develops  acutely  and  stormily.  Almost  always  symptoms  of  a  slowly 
developing  cerebral  disease  precede  it  during  months  or  years,  partly 
in  the  form  of  attacks  or  as  focal  symptoms,  partly  continuous  and 
indicating  diffuse  cerehral  changes.  At  first  these  are  of  a  very 
indistinct  kind.  With  attacks  of  headache,  which  is  usually  increased 
by  pressure  and  while  in  bed,  occasional  attacks  of  vertigo  and  faint- 
ing, aphasic  symptoms,  paralytic  weakness  of  the  extremities,  and 
occasional  paralysis  of  a  cranial  nerve,  there  is  a  change  of  character 
and  mental  habit.  The  patients  often  become  morose,  remarkably 
irritable,  depressed,  and  often  hypochondriac.  Memory  and  speech 
suffer.  Their  mental  powers  decrease;  they  tire  quickly  in  mental 
work,  and  their  feelings  become  dull.  Facial  expression  is  also  duller, 
m.ore  fatuous,  and  the  attitude  is  relaxed.  The  patients  bear  alcohol 
badly,  at  times  have  actual  attacks  of  lethargy,  to  be  followed  by 
weeks  of  troublesome  sleeplessness.  Aitev  longer  or  shorter  duration 
of  these  prodromes,  there  may  be  an  attack  of  furious  mania,  hallu- 
cinatory delirium  with  frightful  anxiety  and  fearful  content  of  hal- 
lucinations ;  or  an  apoplectiform  or  epileptiform  attack  may  mark  the 
outbreak  of  the  real  disease.    After  complete  or  partial  subsidence  of 


596  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

the  symptoms  of  the  seizure,  the  picture  of  progressive  dcniontia 
develops,  or  that  of  dementia  paralytica.  Only  in  rare  cases  does  this 
arise  primarily  out  of  tl)o  prodromal  symptoms. 

In  the  course  of  this  progressive  dementia  tlioi-c  may  be  inter- 
current conditions  of  great  variety — primordial  delusions  of  perse- 
cution and  .of  grandeur,  hallucinatory  delirium,  profound  somnolence 
and  dreamy  states  of  consciousness,  violent  mania,  reaching  the  de- 
gree of  acute  delirium. 

The  fundamental  psychic  weakness,  the  marked  disturbance  of 
consciousness,  the  sudden  occurrence  and  subsidence  of  the  symptom- 
complex,  lend  to  this  disease  peculiar  features  and  point  directly  to 
an  idiopathic  cerebral  disease.  Erlenmeyer  emphasizes  the  partiality 
of  the  psychic  defect  in  cerebral  syphilis;  for  example,  the  complete 
loss  of  ability  to  reckon,  or  of  a  foreign  language  formerly  spoken 
fluently  (as  if  the  patients  had  never  possessed  this  faculty).^  Motor 
disturbances  are  never  wanting  in  this  psychic  disease-picture.  They 
are  extremely  numerous,  change  suddenly',  and  are  in  part  focal  and 
episodic  and  in  part  due  to  diffuse  changes  that  are  continuous  and 
jjrogressive. 

Of  the  motor  disturliances,  especially  important  are  paralyses  of  tlie 
cranial  nerves,  among  them  the  motor  ociili  (ptosis),  abdncens,  trochlearis, 
hypoglossiis,  facialis,  in  this  order  of  frequency.  Hemiplegias  are  infrequent. 
Then  follow  monoplegias  of  the  extremities;  paraplegias  are  the  least 
frequent. 

The  diffuse  distin-bances  of  the  motor  centers  are  general  disturbances  of 
co-ordination  which  frequently  affect  speech  and  thus  cause  the  disease-picture 
to  resemble  dementia  paralytica  very  closely.  Almost  always,  in  cases  of 
chronic  course,  speech  is  implicated.  With  attacks  of  occasional  aphasia  and 
absence  of  speech  there  may  be  stumbling  on  syllables,  scanning  or,  at  least, 
bradyphasic  speech. 

In  all  phases  of  the  disease-picture,  nmning  its  course  as  progressive 
dementia  with  motor  disturbances,  there  may  occur  apoplectiform  and  epi- 
leptiform seizures.  The  former  are  rarely  accompanied  by  loss  of  conscious- 
ness and  infrequently  leave  behind  paralyses  (hemiplegias,  aphasia,  etc.), 
which,  however,  are  usually  incomplete  and  soon  pass  away.  The  epileptiform 
seizures  consist  of  partial  tonic  or  clonic  or  general  convulsions.  They  often 
occur  in  a  series.  Consciousness  is  not  always  lost.  A  frequent  condition, 
emphasized  justly  by  Ileubner,  is  disturbance  of  consciousness  after  psychic  or 
motor  seizures,  characterized  by_  somnolence  that  may  reach  the  degree  of 
coma,  or  confusion,  and  out  of  which  the  patient  can  be  momentarily  awak- 


^  Schule  also  finds  this  syphilitic  dementia  peculiar  in  that  it  develops 
quickly,  that  with  a  general  mental  weakness  it  shows  remarkable  partiality 
in  psychic  defect,  and  that  these  partial  symptoms  of  defect  are  extremely 
variable. 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOINIS.       597 

ened,  coming  to  himself  temporarily,  as  a  healthy  person  comes  to  himself  out 
of  a  drunken  sleep.  The  duration  of  this  condition  may  be  days  or  several 
Aveeks.  It  may  also  occur  as  an  independent  episodic  disturbance.  The  prob- 
able causes  of  these  conditions  are  disturbances  of  circulation  in  the  cerebral 
cortex  due  to  emboli  or  thromboses.  Amblyopia,  that  may  reach  the  degree  of 
amaurosis,  is  not  infrequent,  occurring  episodically,  and  it  maj'  be  accom- 
panied with  negative  findings;  or,  if  it  be  lasting,  with  signs  of  inflamniatiun 
and  atrophy  of  the  optic  nerve. 

Sensory  disturbances  play  an  unimportant  part  in  tlie  (lisease-picture 
(pains  in  the  bones,  neuralgias  and  anesthesias  in  the  doMiain  of  th(!  tii- 
geminus,  rheumatoid  pains  in' the  extremities). 

The  course  of  cerebral  syphilis  on  the  whole  is  progressive,  often 
by  steps,  since  any  new  attack  may  give  the  malady  a  new  impetus; 
but  in  its  general  course,  essentially  progressive,  there  is  an  irregular 
variation  of  symptoms  and  isolated  conditions  like  those  observed 
in  hysteria  (Wunderlich).  Slight  and  grave,  focal  and  diffuse  symp- 
toms, occur  in  striking  and  unusual  combination,  follow  one  another, 
and  make  a  prognosis  for  the  immediate  and  distant  future  ahnost 
impossible.  Death  may  occur  unexpectedly  as  a  result  of  a  new 
attack,  or  the  patient  may  recover  from  the  most  grave  condition. 
The  general  duration  of  cerebral  syphilis  is  months  or  many  years. 
Death  occurs  suddenly  in  a  seizure,  or  with  comatose  symptoms,  or  in 
slow  deterioration  and  general  marasmus. 

Spontaneous  recoveries  have  not  been  observed,  though  by  early 
energetic  treatment  half  of  the  cases  can  be  saved,  and  not  infre- 
quently recovery  can  be  obtained.  Recover}^  however,  is  usually  with 
defect,  at  least  mentally.  "Lues  impresses  upon  the  brain  an  indel- 
ible stamp"  (Wimderlich)  ;  it  remains  less  capable  of  resistance,  and 
relapses  must  be  expected. 

The  first  condition  for  therapeutic  measures  is  recognition  of 
the  specific  nature  of  the  cerebral  disease.  Unfortunately  there  is  no 
specific  symptom.  The  diagnosis  must  always  be  one  of  probability. 
The  first  task  is  anamnestic  and  present  proof  of  syphilis ;  but,  even 
when  this  cannot  be  shown,  it  does  not  in  itself  demonstrate  that  the 
cerebral  malady  is  not  of  syphilitic  nature.  Important  in  the  diag- 
nosis is  the  frequent  absence  of  insuthcient  cause  of  the  disease  other 
than  syphilis,  the  unusual  grouping  of  the  symptoms,  and  the  protean 
changes  in  them.  With  reference  to  the  first  point,  the  occurrence  of 
grave  cerebral  symptoms,  often  in  young  persons,  in  the  absence  of 
all  predisposition,  exciting  causes,  or  causal  disease,  is  striking.  Such 
a  patient,  for  example,  falls  down  in  an  apoplectic  seizure,  and  is 
without  atheroma,  without  heart  disease,  without  Bright's  disease, 
etc.     Another  has  an  epileptic  attack  witliout  any  apparent  cause. 


598  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY, 

Witli  respect  to  the  grouping  of  the  sj'mptoms,  the  mixture  of  focal  and 
ditfuse  symptoms,  and  the  sinuiltaneoiis  occurrence  of  functional  disturbances 
in  disparate  and  Avidely  separated  nervous  paths,  are  remarkable.  Thus,  for 
example,  there  may  be  hemiplegia  complicated  by  paralysis  of  the  motor 
oculi  and  alxlucens;  left-sided  liemiplegia  with  aphasia;  epilepsy  with  osteo- 
copic  pains;    apoplectic  seizures  followed  by  states  of  somnolence. 

As  emphasized  by  Heubner,  weight  should  be  given  to  the  temporary 
character  of  the  signs  of  loss,  with  the  irregular  alternation  of  slight  and 
severe  psychic,  motor,  sensory,  and  sensorial  symptom-complexes. 

In  this  condition  treatment  has  a  fertile  field  when  it  is  instituted  early 
and  energetically:  i.e.,  specific  treatment.  The  more  probable  the  diagnosis 
and  more  threatening  the  symptoms,  the  more  energetic  must  the  treatment 
bo.  "When  the  diagnosis  is  doubtful,  iodide  of  potassium  should  at  least  be 
tried. 

in  the  first  case  an  inunction  cure  should  be  begun,  with  care,  however, 
71  ot  to  restrict  the  patient's  diet.  The  brain  of  the  syphilitic  does  not  bear 
weakening  treatment,  and  least  of  all  venesection.  Where  nutrition  is  good, 
even  forced  inunction  treatment  is  not  dangerous.  It  may  be  combined  with 
iodide  of  potassium  or  alternated  with  this,  or  the  iodide  may  be  used  as  an 
after-treatment.  If  intmctions  are  impossible,  then  injections  of  sublimate 
may  be  employed.  In  chronic  cases  presenting  more  the  picture  of  dementia 
paralytica,  iodide  of  potassium  is  suitable.  A  daily  dose  of  from  8  to  10 
grams  may  be  administered,  if,  following  Erlenmeyer's  instructions,  it  is  ad- 
ministered in  repeated  small  doses  diluted  as  much  as  possible,  and  at  the 
same  time  accompanied  by  the  administration  of  a  strong  infusion  of  calamus 
aromaticus. 

During  conA'alescence  a  fortifying  treatment  is  necessary — meat  and  milk 
diet,  sojourn  in  the  coimtry,  sea-bathing,  cold-water  cures,  and  the  continued 
use  of  iodide  of  iron.  Sulphur  baths  are  not  indispensable.  Since  the  possi- 
bility of  a  recurrence  of  the  maladj'  hangs  over  these  luetic  patients  with 
an  invalid  brain,  mental  and  physical  and  cerebral  dietetics  are  absolutely 
necessary. 

Case  76.— Cerebral  lues  resemljling  the  disease-picture  of  de- 
mentia paralytica.  Improvement  under  specific  treatment.  Exacer- 
bation ending  in  death. 

S.,  aged  40,  saddler,  without  hereditary  predisposition.  Had  a  hard 
chancre  at  the  age  of  24.  He  seems  to  have  had  no  specific  treatment.  Jt 
could  not  be  determined  whether  there  were  secondary  symptoms.  Since  1870 
the  patient  had  suffered  with  frequent  attacks  of  dizziness  and  often  com- 
plained of  dimness  of  vision.  Seven  months  ago  he  was  married.  Soon  after 
his  character  changed.  He  became  irritable,  at  times  apathetic,  distracted, 
and  had  dilTieulty  in  work.  Often  he  could  not  find  the  right  word.  About 
Easter,  1873,  he  is  said  to  have  been  delirious  several  days. 

August  2,  1873,  there  was  a  maniacal  state  of  excitement,  followed  on 
the  4th  by  an  apoplectiform  attack  wliich  passed  off  without  leaving  paralysis. 
On  the  5th,  violent  vomiting.  Vomiting  had  occurred  120  times  from  the  Gth 
to  the  15th,  until  the  patient  was  so  exhausted  he  was  not  able  to  rise  from 
the  bed  without  fainting.     On  account  of  continued  maniacal  excitement  (he 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       599 

wished  to  build  houses,  go  to  America,  etc.)  he  was  admitted  to  the  asylum 
August  15,  1873. 

The  patient  was  greatly  exhausted,  reduced,  extremely  pale,  without 
fever.  Vomiting  lasted  still  some  days.  Consciousness  was  much  disturbed, 
feeling  much  elevated,  thought  increased  in  rapidity,  yet  the  patient  evidently 
had  trouble  to  express  himself.  Consciousness  was  filled  with  grand  delusions, 
as  fantastic,  causeless,  and  illogical  as  in  paralysis.  The  patient  wished  to 
visit  all  the  menageries  in  the  world,  buy  wild  boars,  elephants,  and  make 
enormous  transactions  on  the  stock  exchange.  The  movements  of  the  hands 
were  ataxic,  uncertain;  walking  with  feet  wide  apart,  awkward.  The  right 
pupil  myotic,  double  ptosis.  The  right  superior  and  internal  recti  were 
paretic,  and  there  was  double  vision  looking  inward  and  upward. 

Over  the  whole  body  there  was  complete  analgesia  with  retention  of 
tactile  sensibility,  correct  localization,  and  reflex  excitability.  The  inguinal 
and  cervical  glands  were  somewhat  swollen — a  shining  scar.  On  the  soft 
palate  a  white  cicatrix,  and  other  white  spots  the  size  of  a  bean  deviod  of 
epithelium  and  surrounded  by  a  hyperemic  ring.  The  patient  had  lost  his 
hair  during  the  last  few  years. 

A  diagnosis  of  cerebral  syphilis  was  made,  and  in  spite  of  the  marked 
marasmus,  inunctions  of  mercury,  4  grams  daily,  with  4  graans  of  potas- 
sium iodide,  were  prescribed.  At  the  same  time  the  patient  was  fed 
as  well  as  possible  and  kept  in  bed.  The  delirium  became  more  and 
more  incoherent,  and  the  patient  was  unable  to  distinguish  his  fancy  from 
actuality.  The  development  of  thought  was  difficult,  and  he  had  much  trouble 
often  in  finding  the  desired  word.  Most  recent  events  were  immediately  for- 
gotten. The  patient  had  delusions  about  a  negro  whom  he  thought  had  cut 
off  his  head  with  a  fine  cord,  and  asked  for^  thread  in  order  to  sew  it  on  again. 
He  looked  for  iron  plates  decorated  with  the  crown  of  a  count  in  diamonds 
which  Bismarck  had  presented  to  him;    and  he  believed  himself  a  count. 

September  13th  the  inunction  cure  was  discontinued,  but  potassium 
iodide  (4  grams)  was  continued. 

In  the  course  of  October  the  signs  of  syphilis  in  the  mouth  disappeared 
completely,  nutrition  improved,  and  the  baldness  began  to  give  place  to 
growth  of  hair.  The  psychic  symptoms  did  not  improve;  on  the  contrary, 
mental  weakness  increased  and  the  delirium  took  on  alternately  megalo- 
maniac and  micromaniac  features.  The  patient  thought  two  millions  had  been 
given  to  him,  took  himself  for  a  prince,  lord,  adjutant  of  all  royal  personages, 
traveled  in  very  fast  ships  driven  by  bellows.  He  was  a  great  sorcerer,  visited 
the  north  pole  by  going  under  the  earth,  entering  at  the  crater  of  Vesuvius. 
In  his  periods  of  depression  he  had  consmnption  and  prepared  for  death.  At 
times  brutal  attempts  to  escape,  violence  toward  those  around  him ;  tried  to 
choke  them,  and  destroyed  windows.  On  two  occasions,  in  a  childish  state  of 
depression  for  being  restrainefd,  he  made  two  attempts  at  suicide  by  strangu- 
lation. 

From  the  1st  to  the  20th  of  November,  treatment  with  inunction  (4 
grams),  with  continuance  of  the  iodide  of  potassium.  The  patient  gains  in 
weight  and  his  cheeks  grow  ruddy.  November  21st,  potassium  iodide  discon- 
tinued. Occasional  untidiness  is  shown  to  be  diie  to  anesthesia  of  the  rectum 
and  urethra.  Now  and  then  he  complains  of  rheumatic  pains  in  the  lower 
extremities.     From  December  21st  the  patient  is  again  given  2  grams  of  iodide 


600  SPECIAL  TATIIOLOGY  AND  TITER APY  OF  INSANITY. 

of  potassium  until  April  5,  1874.     Thereafter,  daily,  4  grams  of  the  syrnp  of 
thi  iodide  of  iron. 

In  the  course  of  March,  1874,  the  patient  becomes  quiet,  well  ordered,  his 
consciousness  clears,  and  he  has  insight  into  his  disease,  being  unable  to  under- 
stand how  he  coiild  have  had  such  senseless  ideas.  His  memory  for  the  events 
of  the  disease  is  only  summary.  Exact  examination  sliows  moderate  and 
permanent  dementia.  The  patient  has  not  a  clear  insight  as  to  the  severity 
of  his  disease,  and  he  is  very  optimistic  about  his  present  relative  capabilities; 
his  relations  and  feelings  for  wife  and  relatives  are  dulled,  and  with  that  there 
is  a  certain  emotional  irritability.  Ptosis  and  paralysis  in  the  right  eye 
remain  unchanged. 

In  the  further  course  there  is  no  disturbance  of  speech,  sensibility,  or 
motility,  and  no  signs  of  syphilis.  On  May  3,  1874,  the  patient  resumes  his 
occupation  and  proves  to  be  capable  of  work. 

August  10,  1874,  the  patient  was  again  admitted.  After  decided  sexual 
and  alcoliolie  excesses  toward  the  end  of  July,  he  had  another  attack  of 
mental  excitement  with  vertigo  and  violent  vomiting,  just  like  the  first. 

The  patient  presented  the  same  mental  picture  as  on  his  first  admission: 
i.e.,  great  mental  weakness  and  confusion,  absence  of  critical  power,  enormous 
and  grand  delusions;  but,  in  contrast  with  his  previous  condition,  his  state 
of  nutrition  was  excellent. 

The  former  motor  disturbances  of  the  right  eye  existed  unchanged.  Re- 
sumption of  inunctions  and  treatment  with  iodide  of  potassium  this  time  had 
no  efTect.  The  patient  presented  a  peculiar  change  of  expression  similar  1o 
one  intoxicated.  The  muscles  of  the  lips  and  cheeks  on  the  left  side  were 
often  paretic.  From  October  on  there  was  progressive  amblyopia  in  both 
eyes,  which  caused  the  patient  to  wish  to  go  to  England  "to  have  new  eyes 
put  in."  In  March,  1875,  there  was  slight  stumbling  on  syllables  and  swallow- 
ing of  syllables,  which  «ontinued  thereafter  with  varying  intensity.  In  the 
beginning  of  April,  ataxia  and  trembling  in  the  upper  extremities  came  on. 
On  May  11,  1875,  two  attacks  of  vertigo.  In  the  course  of  the  summer  there 
developed  extreme  (syphilitic)  chlorosis,  and  in  November  there  was  tempo- 
rary retention  of  urine  and  attacks  of  vomiting.  In  December  speech  became 
interrupted,  slow,  and  absolutely  wanting  in  states  of  excitement.  Syllables 
were  incorrectly  accented  and  often  explosively  uttered.  Now  there  were 
frequent  signs  of  vascular  paralysis  in  the  domain  of  the  cervical  sympathetic. 
Ptosis  came  on  in  the  left  eyelid.  In  this  long  period  there  was  progressive 
dementia  and  absolutely  incoherent  delusions  of  grandeur.  The  patient  said 
he  was  holy,  had  discovered  an  entirely  new  portion  of  the  world  through  the 
firmament.  He  was  the  most  skillful  cook,  and  at  the  same  time  a  prince. 
Now  and  then  refusal  of  food  because  the  millions  of  gods  had  forbidden  him 
to  eat  or  Bismarck  had  poisoned  his  food.  In  the  course  of  the  year  1876  the 
malady  had  progressed  decidedly. 

The  increasing  anemia  and  difficulty  of  movement  made  it  necessary  to 
keep  him  in  bed.  The  disturbance  of  speech  increased  so  that  at  times  the 
patient  was  unable  to  make  himself  understood  on  account  of  stumbling  on 
syllables  and  stuttering.  With  this  there  w^as  amnesic  aphasia.  There  was 
profound  dementia,  with  remains  of  grand  delusions.  He  stated  that  he  had 
seven  lives,  seven  genitals,  and  w^as  seventy-seven  million  years  old.  The  gods 
would  carry  him  away  in  seven  days,  and  then   he  would   ili>appoar.     Fi-nm 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       GOl 

May  on  there  were  a,t  times  attacks  of  vomiting  and  retention  of  urine, 
meteorism,  and  symptoms  of  collapse. 

From  January  8,  1877,  there  were  frequent  apoplectiform  and  epilepti- 
form seizures.  The  temperature  rose  to  from  39°  to  40°  C.  On  the  lüth 
death  occurred. 

Autopsy  (twenty  hours  after  death):  Cranium  and  dura  normal.  Over 
the  convexity  the  soft  membranes  are  extremely  delicate,  with  the  exception 
of  slight  cloudiness  along  the  large  vessels  over  the  parietal  lobes,  and  yel- 
lowish-white thickenings  of  the  pia,  the  size  of  millet-seeds,  over  the  temporal 
lobes.  At  the  base,  however,  the  membranes  are  much  clouded  and  thickened, 
especially  on  the  right  side.  '  The  right  motor  ocidi  is  scarcely  half  the  size  of 
the  left,  and  can  be  removed  from  the  thickened  arachnoid  only  with  gi-eat 
care.  The  other  cranial  nerves  at  the  base  are  uninjured.  The  right 
vertebral  artery  and  the  Sylvian  artery,  as  well  as  the  commencement  of  the 
basilar,  are  thickened,  rigid,  sclerotic,  but  not  obstructed.  Nevertheless  over 
the  convexity,  as  well  as  at  the  base,  even  where  the  pia  is  neither  clouded 
nor  thickened,  there  are  spots  where  it  cannot  be  removed  from  the  cortex 
without  bringing  softened  cerebral  substance  with  it.  This  is  most  marked 
at  the  tip  of  the  frontal  lobes. 

The  convolutions  of  the  frontal  lobes  are  very  narrow,  and  in  places 
below  the  general  level.  The  cortex  is  much  thinned,  yellowish-gray,  softened, 
and  infiltrated  with  serum.  The  brain  is,  in  general,  very  anemic,  has  a  moist 
shiny  appearance,  and  retracts  on  section.  The  vessels  are  dilated,  and  the 
lumina,  of  tlte  vessels  become  prominent.  The  ventricles  are  decidedly  dilated 
and  filled  with  clear  serum.  A  few  granulations.  All  the  inner  and  external 
parts  of  the  body  are  very  poor  in  blood. 

On  the  left  under  surface  of  the  epiglottis  the  mucous  membrane  is  pig- 
mented and  presents  superficial  loss  of  substance.  In  the  pharynx,  chronic 
catarrh.  The  apex  of  the  left  lung  is  retracted  by  scars,  and  pigmented.  The 
lower  lobe  of  the  left  lung  is  in  a  state  of  gray  hepatization.  The  edges  of  the 
bicuspid  valves  are  shrunken  and  thickened.  The  internal  surface  of  the 
aorta  is  smooth  and  unaltered. 

Liver  fatty.  Portal  vein  intact,  though  on  the  anterior  surface  of  the 
right  lobe  of  the  liver  the  serous  membrane  is  thickened,  and  beneath  it, 
extending  into  the  parenchyma,  there  is  a  hard,  white,  fibrous  callosity.  No 
other  traces  of  visceral  lues. 

Case  77. — Progressive  dementia  with  motor  disturbances,  of 
luetic  origin.  Treatment  with  potassiimi  iodide.  Lasting  improve- 
ment. 

W.,  official,  aged  35,  married,  was  admitted  to  the  asylum  May  27,  1876, 
with  the  diagnosis  of  dementia  paralytica.  The  patient  was  of  a  neuropathic, 
eccentric  family.  The  father  was  genei'ally  considered  insane.  At  the  age  of 
22  the  patient  had  a  hard  chancre,  and  afterward  general  luetic  symptoms. 
The  treatment  seems  to  have  been  specific,  but  not  very  energetic.  One  year 
after  infection  there  was  an  apoplectic  attack,  which  left  behind  facial 
paralysis.  It  is  said  that  no  traces  of  syphilis  were  to  be  observed.  There- 
after, however,  the  patient  was  frequently  troubled  wjth  headache  and  intol- 
erance of  alcohol,  and  fatigued  quickly  in  mental  work.  In  1873,  at  the 
Vienna  Exposition,  he  is  said  to  have  committed  excesses  in  potu  et  venere 


602  SPECIAL  PATHOLOCY  AND  THERAPY  OF  INSANITY. 

and  thereafter  was  nervously  excited,  and  for  a  long  time  sleepless;  and  he  is 
said  to  haA-e  recovered  after  treatment  in  a  hydropathic  sanitarium.  Three 
3'ears  ago  there  -was  right-sided  facial  paralysis.  The  patient  is  said  at  that 
time  to  have  had  drawling  speech  for  a  time. 

In  tlie  summer  of  1875,  at  a  time  wlien  the  patient  was  under  great 
mental  strain,  sleeplessness  and  loss  of  weight  came  on.  In  March,  1876,  the 
patient  became  mentally  changed,  peculiar,  irritable,  distracted,  forgetful.  At 
limes  he  was  anxious  and  worried  aboxit  the  future,  feared  that  his  family 
would  be  forced  to  suffer  privations;  then  he  would  become  gay  and  careless 
to  the  degree  of  joyousncss.  In  May,  1876,  there  was  again  troublesome 
sleeplessness.  The  patient  became  excited,  incapable  of  work,  and  sensitive  to 
light  and  noise. 

On  admission  the  patient  seems  slightly  congested,  as  if  drunk,  with 
relaxed,  slightly  demented  facial  expression  and  apathetic  manner.  He  does 
not  recognize  the  place  wiiere  he  is,  thinks  the  following  day  that  he 
has  been  here  several  weeks,  forgets  in  the  next  moment  visits,  meals,  while 
liis  memory  for  past  events  is  quite  con-ect.  He  himself  notices  that  he  is 
forgetful,  that  for  a  long  time  he  has  been  unable  to  carry  on  his  business 
properly,  and  tliat  he  has  made  mistakes  in  counting  money,  in  accounts,  etc. 
The  patient  cannot  repeat  long  sentences  that  are  recited  to  him.  His  speech 
is  disturbed,  slow,  and  slightly  liesitating.  His  tongue  trembles,  and  in  the 
movements  of  the  face  in  speaking  and  otherwise  the  lips  tremble,  and  there 
are  fibrillar}'  twitchings  in  the  facial  muscles.  The  right  side  of  the  face, 
especially  about  the  mouth,  is  paretic;  there  is  slight  left  ptosis  and  paresis 
of  the  inferior  rectus.  The  pupils  axe  moderately  dilated  and  equal,  reacting 
promptly.  The  movements  of  the  extremities  are  somewiiat  uncertain,  and 
there  are  often  slight  twitches  in  them.  The  gait  is  slightly  staggering,  uncer- 
tain, and  the  feet  wide  apart.  Most  careful  examination  reveals  no  traces  of 
lues.  The  ophthalmoscope  shows  the  left  arteries  narrow;  some  venous 
stasis.  On  the  right  side  the  external  half  of  the  disc  is  gray  and  blurred 
(edema).  The  patient  is  hyperesthetic  to  noises,  sleeps  little.  He  wanders 
about  dreamily,  without  distinct  consciousness  of  time  and  place,  tries  often 
to  run  away,  and  repeatedly  weeps  childishly  because  his  wife  does  not  visit 
liim,  and  because  here  in  prison  he  must  pass  his  time  in  catching  flies.  On 
one  occasion,  for  hours,  he  was  bewailing  his  fate  because  he  was  ruined  here 
and  treated  with  poisons.  He  was  a  lost  man,  asked  for  his  coffin,  and  to  be 
laid  in  it.  "Oh,  how  bitter  it  is  to  die  and  not  to  be  able  to  see  my  wife  once 
more." 

The  patient  is  given  batlis,  which  overcome  the  sleeplessness.  Owing  to 
the  luetic  history,  potassium  iodide  is  prescribed  and  gradually  increased  to  6 
grams  daily,  until  acne  and  symptoms  of  slight  intoxication  occur.  By  tlie 
middle  of  June  consciousness  cleared,  and  the  motor  disturbances  were  reduced 
to  a  minimum. 

Further  observation  of  this  interesting  case  was  prevented  by  his  sudden 
removal  from  the  asylum,  July  4,  1876.  When  discharged  the  patient  pre- 
sented a  slight  degree  of  psychic  weakness,  imperfect  speech,  and  slight  twitch- 
ing of  the  facial  muscles. 

To  the  kindness  of  Director  Birnbacher,  of  the  asylum,  I  owe  tliese  fur- 
ther notes  about  the  patient:  Soon  after  his  discharge  from  the  institution  he 
had  an  apoplectiform  attack,  followed  by  decided  loss  of  mental  functions  and 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       603 

unilateral  paresis.  "The  man  was  like  a  demented,  silly  child."  After  six 
months  he  recovered  so  far  that  he  could  at  first  copy,  and  soon  after  do 
light  original  work.  During  the  last  two  years  the  patient  ha.s  been  more  or 
less  occupied  as  a  lawyer.  "With  the  exception  of  slight  dementia  he  might 
be  described  as  mentally  intact." 


CHAPTER  IV. 
Senile  Dementia. 


In  advanced  age  the  brain  undergoes  a  retrograde  metamorpho- 
sis which  is  only  one  of  tlie  manifestations  of  a  general  physical  involu- 
tional process. 

While  vegetatively  this  is  senile  marasmus,  the  organic  cerebral 
change  results  in  change  of  mental  disposition  and  character.  The 
man  whose  brain  is  aging  becomes  more  circumspect  in  his  opinions 
and  judgments.  His  power  of  intellectual  assimilation  is  lessened; 
his  imagination  is  not  so  lively  and  warm  as  in  youth;  thought  be- 
comes slowed,  memory  imperfect,  the  circle  of  ideas  becomes  more 
limited,  and  the  will,  no  longer  strong,  is  more  easily  influenced. 

The  aged  man  lives  principally  in  the  past;  he  is  conservative, 
mistrustful  of  what  is  new,  and  an  egotist  and  laudator  temporis  acti 
(Legrand  du  Saulle). 

Frequently  this  change  does  not  stop  with  the  senile  alteration 
of  character  described,  but  advances  to  a  state  of  mental  weakness, 
which  may  reach  the  most  extreme  degree  of  dementia. 

The  clinical  picture  of  senile  dementia  corresponds  anatomically  with  an 
atrophy  of  the  cerebral  hemispheres  and  simultaneous  atheroma  of  the  cere- 
bral vessels.  The  atrophy  is  always  niost  distinct  in  the  convolutions  of  the 
forebrain,  the  cortical  layers  of  which  are  largely  obliterated,  and  present  a 
yellowish  color  on  section. 

Microscopically  there  are  found  changes  in  the  nerve-cells  of  the  cortex 
(simple  atrophy,  fatty  degeneration,  fatty  pigmentary  degeneration)  and  in 
the  vessels  (atheroma,  obliteration  due  to  atrophy,  capillary  aneurisms).  With 
the  cerebral  atrophy  there  are  observed  compensatory  thickenings  of  the 
cranium,  accumulation  of  serum  in  the  subarachnoid  space  and  the  ventricles, 
pachymeningitis  externa  and  interna,  and  edema,  of  the  pia;  often,  too,  partly 
causal,  partly  as  complicating  conditions,  focal  changes,  in  the  form  of 
apoplectiform  scars  and  spots  of  softening  (atheromatous  encephalitis). 

This  atrophy  may  be  primary,  or  it  may  be  due  to  focal  processes,  espe- 
cially when  they  are  multiple. 

The  initial  symptoms  of  the  disease-picture  are  those  of  the 
senile  change  of  character,  which  increase,  and  cause  to  become  espe- 
cially prominent,  egotism,  pride,  distrust,  irritability,  and  lapses  of 
judgment   and  memory,  especially   for  recent   events.      Not   infre- 


604  SPECIAL  PATHOLOGY  AXD  TTTERAPY  OF  INSANITY. 

quently,  with  this  there  are  vertiginous,  apoplectic,  or  epileptoid 
attacks,  and  somnolence  or  sleeplessness,  with  nightly  wandering 
about.  In  otlu^r  cases  a  rt'inarkable  lowering  of  etliic  feeling  mani- 
fests itself,  and  in  connection  with  sexual  excitcmtMit  lliore  may  then 
be  gross  inclinations,  to  wliicb  cliildi-cn  esju'cially  fall  \iftims.  After 
a  sborter  or  longer  lime  of  tliis  jn'odromal  stage  tlu'  picture  of  senile 
])ersecutory" insanity  or  of  senile  mania  {vide  page  153)  may  develop 
and  lead  to  dementia;  or  the  dementia  is  primary  and  progressive, 
developing  immediately  out  of  the  prodromal  stage.  Then  there  is 
rapid  development  of  profound  loss  of  memory,  which  affects  espe- 
cially recent  events,  and  sometimes  even  the  events  of  the  last  ten 
years  are  quite  obliterati'il  I'l-oiii  tlie  mind,  so  tliat  the  patient  lives  in 
time  long  passed.  A  profound  disturbance  of  consciousness  affecting 
time  and  place  also  appears.  The  patients  wander  about  and  get  lost 
in  the  street,  or  even  in  their  own  houses;  misplace  their  things,  and 
then  think  they  have  been  stolen;  or  take  the  property  of  others,  and 
the  like.  In  thought  there  may  be  observed  incoherence  and  distrac- 
tion. The  feelings  become  unstable ;  childish  joy  and  laughter  alternate 
with  phases  of  painful,  often  hypochondriac,  depression,  which  may 
reach  the  degree  of  tcedium  vitcB.  The  patients  wander  about  dream- 
ily at  night,  busy  themselves  with  their  effects  without  reason,  break 
awkwardly  what  comes  to  their  hands,  and  cannot  find  their  beds 
again.  This  nightly  restlessness  is  often  due  to  feelings  of  fear  or 
abrupt  ideas  of  persecution  and  hallucinations. 

In  this  picture  of  mental  decay  there  may  be  episodically  melan- 
cholic and  maniacal  states  of  excitement,  as  well  as  delusions  of 
persecution  {vide  page  154).  Not  infrequently,  as  further  somatic 
intercurrent  symptoms,  there  are  apoplectic  and  epileptiform  attacks, 
due  sometimes  to  hemorrhages  or  to  softening,  sometimes  to  tem- 
porary disturbances  of  circulation  and  localized  edema.  Following 
these  attacks  there  are  frequently  paralyses  of  a  focal  character 
(hypogiossus,  facial,  hemiplegia).  If  the  patients  live  long  enough, 
they  become  apathetically  demented,  unclean,  gluttonous,  and  fall 
into  a  state  of  progressive  psychic  and  general  motor  paralysis. 

The  course  of  senile  dementia  is  chronic,  lasting  several  years, 
though  there  are  rare  cases  of  acute  course  lasting  only  a  few 
months. 

Death  is  usually  due  to  brain  complications,  pneumonia,  affec- 
tions of  the  bladder,  decubitus,  or  colliciuative  diarrliea.  Therapeu- 
tically we  are  helpless  before  the  degenerative  process  which  lies  at 
the  foundation  of  the  disease.  Good  food  and  stimulation  of  the  cir- 
culation are  all  that  can  be  suggested  for  treatment.    The  predomi- 


DISEASES  WITPI  PREDOMINATINC  TSYCTTTC  SYMPTOMS.       cor, 

nating  restlessness  of  these  patients  at  night  seems  to  be  a  symptom 
of  relative  inanition;  at  any  rate,  a  full  meal  at  night  and  spirits 
frequently  have  a  quieting  effect.  If  narcotics  are  indicated,  opium 
is  best  as  a  sedative  and  hypnotic,  while  chloral  hydrate,  owii)g  to 
the  brittle  state  of  the  vessels  and  fatty  degeneration  of  the  heart 
usually  present,  is  not  wil^hout  danger. 

Case  78. — Senile  melancholia.    Termination  in  senile  dementia. 

Mr.  H.,  banker,  aged  65,  was  admitted  to  tlie  asylum  in  the  middle  of 
July,  1864.  Since  Maj'  there  had  been  symptoms  of  melancholia  with  twdliini 
viUc,  great  restlessness,  nihilistic  delusions  of  being  ruined  and  being  unable 
longer  to  pay  debts.  With  this  there  was  profound  disturbance  of  conscious- 
ness, with  weakness  of  memory,  and  now  and  then  voices  saying  he  had  done 
senseless  things  and  cheated. 

On  admission,  agitated  melancholia  with  gTeat  disturbance  of  conscious- 
ness; hot,  red,  congested  head;  troublesome  restlessness,  which  impelled  the 
patient  to  rub  and  scratch  his  body. 

Great  painful  resistance;  complaints  that  he  did  not  know  what  was 
taking  place  around  him,  that  his  memory  was  gone,  that  he  could  no  longer 
extricate  himself  from  the  continual  dilemma  of  opposite  ideas,  and  that  he 
now  knew  nothing  more  of  what  was  taking  place  in  the  external  world  (dis- 
turbance of  consciousness  and  hindered  apperception).  With  this,  discon- 
nected delirium,  constantly  crying:  "For  God's  sake,  no;  what  have  I  done?" 
(impulsive  activity  of  thought  with  incapability  of  following  out  a  series  of 
ideas).  To  this  picture  of  incoherent,  agitated  melancholia,  with  great  con- 
fusion and  distiu-bance  of  consciousness,  there  were  added  uncleanliness,  re- 
fusal of  food,  and  nihilistic  delusions.  He  thought  himself  dead,  incapable  of 
running,  of  changed  character,  empty,  stopped  up,  decaying,  the  world  was 
upside  down,  everj'^thing  was  foolish,  and  all  only  for  form.  EA-erything  was 
false,  lost;  no  bed,  no  more  food;  another,  not  he,  had  eaten  it.  He  had  lost 
his  memory  and  become  some  one  else. 

These  delusional  ideas,  indicating  profound  disturbance  of  consciousness 
of  self  and  the  world,  are  always  expressed  by  the  patient,  without  deep 
emotional  coloring,  in  a  monotonous  and  desultory  way.  There  was  a  regular 
alternation  of  relatively  Cjuiet  and  restless  days  to  be  noted,  and  in  the  latter 
the  patient  denied  everything.  During  the  latter  the  patient  was  entirely 
negative,  very  resistive,  scratched  his  face  and  body,  and  refused  food.  Dis- 
tressing anxiety  and  senile  pruritus  seem  to  be  the  cause  of  this  constant 
scratching.  Now  and  then  complaints  of  headache,  dizziness;  hot  congested 
head;  occasional  complaints  of  voices  and  foul  odors,  which  gave  rise  to  the 
delusion  that  everything  was  in  a  state  of  decay.  Toward  the  end  of  1864 
emotional  affects  diminished,  Avhile  the  nihilistic  complaints  continued,  always 
more  fragmentary  and  incoherent,  and  the  disturbance  of  consciousness  made 
constantly  further  progress.  The  heart-sounds  were  continuously  dull  and 
impure,  and  the  arteries  rigid  and  tortuous.  In  the  course  of  the  summer, 
1866,  there  was  progressive  marasmus.  In  June,  hematoma  of  ear;  in  July, 
general  furunculosis.  In  March,  1867,  the  patient,  in  an  advanced  state  of 
dementia,  with  the  remains  of  mhüistic  delusions  without  affect,  died  of 
pneumonia.  , 


606  SPECIAL  TATHOLOGY  AND  THERAPY  OF  INSANITY. 

Autopsy  (twenty-four  hours  after  death) :  The  skull  is  heavy,  bone  com- 
pact, hard,  -with  disappearance  of  the  diploii.  In  certain  places  on  the  inner 
surfa<?e  of  the  frontal  and  parietal  bones  there  were  osteophytes  the  size  of 
poppy-seeds.  Sutures  complete.  Dura  firmly  adherent  to  the  skull,  and  sur- 
face matted.  Its  inner  sxirface  covered  with  rusty-colored  membrane  of  new 
formation.  Only  a  few  drops  of  serum  in  the  subarachnoid  space.  Pia  in 
general  anemic;  edematous  over  the  frontal  lobes;  injected  only  over  the 
right  occipital  lobe,  with  the  cortex  beneath  softened  to  a  pulp.  Section 
shows  this  to  be  of  gray-white  color  and  softened;  the  white  substance  be- 
neath (o  the  extent  of  three  centimeters  in  a  state  of  gray-wliite  softening 
(white  encephalomalacia).  The  pia  is  easily  removed  from  the  cortex,  and 
nowhere  thickened.  The  first  and  second  frontal,  as  well  as  the  anterior  and 
posterior  central  convolutions,  are  much  below  (he  general  level,  and  flattened. 
The  cortex  of  the  hemispheres  is  everywliere  yellow  in  color  and  translucent: 
the  white  substance,  noticeably  in  the  posterior  lobes,  presents  dilated  vessels. 
The  ventricles  are  not  dilated ;    the  epcndyma  is  a  little  thickened. 

The  carotids  are  extremely  atheromatous,  with  knots  here  and  there, 
and  the  basilar  arterj^  presents  in  places  cirsoid  dilatation.  Other  parts  of  the 
brain,  as  well  as  tlie  spinal  cord,  are  without  apparent  change.  The  lower 
lobe  of  the  right  lung  is  in  a  state  of  gray  hepatization.  The  mitral  valves 
arc  tliickened  and  retracted.  The  aortic  valves  atheromatous,  but  sufficient. 
Heart-muscle  yellowish  brown  and  fatty  on  section.  On  the  superior  wall  of 
the  arch  of  the  aorta  there  is  a  rough,  hard,  atheromatous  spot  the  size  of  a 
silver  quarter.  Smaller  spots  of  the  same  kind  are  fovind  on  the  wall  of  the 
descending  aorta.  For  the  extent  of  half  an  inch  the  large  intestine  is  con- 
stricted to  the  size  of  a  finger  at  a  point  six  inches  from  its  termination. 

Anatomic  diagnosis:  Atrophy  of  the  brain;  encephalitis  of  the  right 
posterior  lobe  of  the  brain;  internal  pachymeningitis;  right  croupous  pneu- 
monia;   arteriosclerosis;    fatty  degeneration  of  the  heart. 

Case  79. — Senile  dementia.    Intercurrent  mania. 

K.,  artisan,  admitted  December  18,  1875.  He  had  one  insane  sister,  and 
in  1848,  for  several  weeks,  he  was  maniacal.  He  was  an  industrious,  moral 
workman,  and  had  accumulated  quite  a  competency.  In  the  course  of  the 
year  1875  the  patient  became  forgetful,  distracted,  suspicious,  and  avaricious. 
He  often  had  urinary  troubles  (hj-pertrophy  of  the  prostate).  In  October  an 
apoplectiform  attack  with  transitory  paralysis  of  speech.  After  this  the 
patient  was  sleepless,  wandered  about  restlessly,  and  began  to  make  silly  pur- 
chases and  indecent  proposals  to  women.  At  night  he  went  about  in  saloons. 
"NMien  his  relatives  remonstrated  with  him  for  this,  he  became  brutal  and  said 
lie  thought  he  had  a  right  in  his  declining  years  to  enjoy  life;  indeed,  he  was 
growing  younger  and  licalthier  every  day. 

After  December  10th  he  had  seven  epileptiform  attacks,  and  since  then 
the  patient  had  become  more  excited,  more  restless,  making  senseless  plans, 
drinking,  and  throwing  his  money  away.  He  entertained  ideas  of  building 
enormous  breweries,  gi-eat  buildings,  a  whole  street  which  should  be  named 
for  him.  One  day  after  he  had  cut  off  the  wings  and  then  the  heads  of  his 
geese,  and  finally  began  to  threaten  his  relatives,  he  was  sent  to  the  clinic. 

On  admission  the  patient  appeared  congested,  with  shining  eyes  and 
myotic  pupils.    At  first  he  did  not  recognize  his  situation,  made  senseless 


DISEASES  WITH  PREDOMINATING  PSYCHIC  SYMPTOMS.       607 

plans,  and  was  impulsive  and  even  obscene  toward  the  female  nurses.  He  was 
full  of  plans  and  wishes,  talkative,  without  reason,  and  sleepless.  Silly  manner, 
superficiality  of  affects,  lapses  of  judgment  and  memory,  great  forgetfulness; 
and  the  ease  with  which  his  attention  could  be  distracted  gave  to  the  maniacal 
picture  features  of  mental  weakness.  Physically  there  were,  along  with 
decided  fluxion  to  the  head,  symptoms  of  advanced  senility,  rigid  and  very 
tortuous  arteries,  and  emphysema. 

The  patient  was  very  unstable  in  his  sense  of  time  and  place.  At  night 
he  slept  little,  wandered  about  in  his  room,  looked  for  his  things,  could  not 
find  them,  and  during  the  day  he  went  about  in  a  dreamy  state,  building  air- 
castles,  saying  that  the  whole  hospital  belonged  to  him,  and  that  he  would 
change  it  into  a  palace. 

Aside  from  slight  tremor  of  the  lips,  there  were  no  motor  disturbances. 
Several  times,  with  violent  congestion  of  the  brain,  there  was  violent,  painful, 
angry  excitement,  in  which  he  tried  to  escape  and  became  brutal  and  even 
aggressive  toward  those  around  him;    but  he  was  always  easily  quieted. 

Under  treatment  with  baths  and  injections  of  morphine  (0.01  gram  twice 
daily)  the  excitement  subsided  toward  the  beginning  of  January,  1876.  The 
patient  had  quiet  nights,  corrected  his  ideas,  and  showed  even  traces  of  insight 
into  his  disease.  The  mental  weakness  now  became  more  apparent,  especially 
in  his  childish  weeping  because  he  was  not  allowed  to  return  to  his  family. 

Toward  the  end  of  January  it  was  possible  to  return  him  to  his  rela- 
tives.    He  was  quiet,  but  much  demented. 

Case  80, — Senile  dementia.    Delusions  of  persecution. 

M.,  aged  7S,  pensioned  official,  was  admitted  to  the  asylum  October  2, 
1874.  His  mental  powers  had  failed  during  the  last  three  years.  The  patient 
was  forgetful,  distracted,  had  often  lost  himself  in  the  street  and  in  his  own 
home,  mislaid  his  things  and  thought  that  they  had  been  stolen.  Four  months 
ago  there  was  an  apoplectiform  attack.  Since  then  the  patient  had  been  rest- 
less, suspicious,  expressed  at  times  delusions  of  poisoning,  was  afraid  of 
thieves,  anxious  at  night,  and  sleepless.  The  mental  weakness  made  great 
progress.  He  had  small  sense  of  time  and  place,  with  frequent  oppression  in 
his  chest,  difficulty  of  breathing,  headache,  dizziness,  and  increasing  weakness 
of  the  legs,  with  which  there  was  manifestation  of  partly  hypochondriacal, 
partly  hostile  ideas  of  others. 

A  short  time  before  admission  he  had  pronounced  delusions  of  poisoning, 
and  since  these  concerned  his  relatives  and  were  to  the  effect  that  they  were 
seeking  his  life,  he  became  more  and  more  excited  and  finally  refused  food, 
and  this  led  to  the  decision  to  send  him  to  the  asylum. 

The  patient  presents  an  exquisite  picture  of  senile  marasmus.  The 
arteries  are  rigid;  the  pulse  irregular,  inteiTupted;  the  lips  are  cyanotic,  and 
there  is  edema  of  the  feet  and  eyelids;  and  cardiac  dullness  is  decidedly  in- 
creased.    The  first  sound  of  the  bicuspid  valves  is  replaced  by  a  mitrmur. 

The  patient  is  very  weak  mentally,  uncertain  in  his  sense  of  time  and 
place,  and  his  memory  is  so  feeble  that  he  cannot  retain  recent  impressions. 
He  is  easily  diverted  and  whines  childishly.  He  sleeps  little  at  night,  wanders 
around  dreamily,  disturbed  by  apprehensive  restlessness,  has  fear  of  thieves 
and  murderers,  and  cannot  find  his  way  back  to  bed.  He  says  that  his  people 
wish  to  poison  him.    He  has  seen  his  relatives  put  arsenic  on  his  plate.     He 


608  SPECIAL  rATHOTX)r;Y  AND  THERAPY  OF  IXSAXITY. 

has  never  tasted  the  poison,  but  he  has  felt  its  effect  in  niiinerons  physical 
symptoms  (due  to  his  cardiac  trouble),  and  tluis  recognized  why  he  cannot 
sleep. 

In  the  asylum  he  often  shows  suspicion,  refuses  medicine  because  it  has 
fly-powder  in  it,  and  food  because  there  is  arsenic  in  it.  However,  his  resist- 
ance is  easily  overcome.  Very  frequently  he  thinks  something  is  put  in  his 
food  in  order  to  keep  him  from  sleeping.  His  relatives  persecute  him  here 
also.  They  have  sent  him  here  in  order  to  rob  and  get  control  of  his  whole 
fortime.  Profound  affect  is  wanting;  only  now  and  then,  especially  at  night. 
are  there  spontaneous  attacks  of  fear,  which  call  up  into  consciousness  the 
delusions.  He  then  cries  and  weeps  like  a  child,  calling  tor  help.  Frequent  at- 
tacks of  dizziness.    Progressive  loss  of  meniory  and  clouding  of  consciousness. 

After  the  middle  of  December,  decided  diltioulty  of  respiration  and  gen- 
eral edema  were  the  signs  of  cardiac  weakness.  Death  with  symptoms  of 
edema  of  the  lungs,  December  25th. 

Autopsy:  Hyperostosis  of  the  skull.  Dura  and  pia  without  change. 
Frontal  and  parietal  convolutions  narrowed,  and  here  and  there  below  the 
general  level.     Extreme  atheroma  of  the  arteries  at  the  base. 

On  the  basal  surface  of  the  left  occipital  and  left  parietal  lobes  therfe  is 
a  longitudinal  enc^phalitic  focus  filled  witli  cloudy  serum  and  covered  by  the 
pia,  which  extends  into  the  inner  half  of  the  third  temporal  convolution,  on 
the  one  hand,  and,  on  the  other,  rea<>hes  to  the  posterior  horn  of  the  ventricle 
and  communicates  with  it.  The  walls  of  the  sack  are  covered  with  a  mem- 
brane and  are  ocher  colored.  The  left  perforating  artery  is  changed  into  a 
strand  of  connective  tissue  and  is  lost  in  the  cyst. 

A  second  cyst  three  centimeters  long  and  yellowish  in  color  occupies  half 
of  the  transverse  convolution  which  forms  the  second  frontal  sulcus;  a  third 
and  similar  cyst  occupies  the  spot  where  the  angular  gyrus  passes  into  the 
second  occipital  convolution;  and  a  fourth  lies  in  the  calcarine  fissure.  The 
brain  is  edematous  and  anemic.  The  heart  is  twice  the  normal  size,  the  left 
ventricular  wall  thickened.  The  aortic  and  tricuspid  valves,  thickened  and 
shrunken;  the  beginning  of  the  aorta  dilated,  its  walls  in  the  initial  stage  of 
atheromatous  degeneration.     The  heart-muscle  is  yellowish  and  fatty. 


PART  SIXTH. 
Arrest  of  Psychic  Development. 


liSr  any  of  the  phases  of  the  process  of  development  through 
which  the  central  nervous  system  must  pass  until  it  reaches  its  indi- 
vidual completion,  disturbing  influences  may  intervene  which  hinder 
the  development  of  the  brain  or  one  or  more  of  its  parts,  or  even 
cause  complete  arrest  of  development.  As  a  result  of  this,  as  a  rule, 
the  functional  activities  of  the  psychic  organ  are  lastingly  interfered 
with  or  profoundly  injured.  Such  mental  defects,  or  deficiencies  thus 
induced,  are  commonly  called  arrests  of  mental  development. 

Clinical  consideration  of  these  mental  insufficiencies  encounters 
great  difficulties,  since  there  is  an  immense  number  of  faculties, 
alterations  of  which  differ  in  nature  and  intensity;  and  moreover 
they  occur  at  different  periods  of  psychocerebral  development. 

In  general,  two  clinical  groups  may  be  differentiated,  in  the  first 
of  which  the  intellectual  faculties  show  marked  defect  (intellectual 
idiocy)  and  this  dominates  the  whole  clinical  picture;  while  in  the 
second  group,  though  intellectual  defect  is  not  entirely  wanting,  it 
is  much  less  prominent  than  the  distortion  of  the  ethic  functions 
(moral  idiocy).  There  are,  too,  in  both  groups,  numerous  variations 
of  degree  (idiocy  and  imbecilit}^,  moral  or  intellectual),  as  well  as 
numerous  clinical  varieties  (active,  or  erethistic,  and  passive,  or 
torpid,  forms).  Clinical  cases  of  moral  idiocy  must  be  regarded  as 
milder,  since  only  the  higher  intellectual  functions  are  profoundly 
touched,  with  escape  of  formal  thought  and  power  of  judgment 
(understanding) ;  but  the  individual,  nevertheless,  is  robbed  of  what 
is  generally  called  reason:  i.e.,  he  is  unable  to  acquire  and  appreciate 
the  fundamental  principles  and  ideas  of  higher  moralit}^,  and  in 
consequence  reasonable  views  of  life  as  the  motive  of  purposeful 
activity  and  as  the  fvindamental  condition  of  character,  with  insight 
into  the  value,  consequence,  and  duties  of  the  individual  in  society, 
are  not  developed. 

Thus  this  slighter  form  of  mental  insufficiency  is  practically  and 
socially  of  greater  importance,  because  the  moral  defect  causes  lack 
of  mental  independence  which  may  reach  the  degree  of  absolute  in- 

^'  (609) 


610  SPECIAL  rATHOLOGY  AND  THERAPY  OF  INSANITY. 

capability  of  winning  a  social  standing,  and  living  in  accordance 
with  it. 

Anatomically  cases  of  moral  idiocy  are  less  severe,  for  the  brain- 
changes  upon  which  it  depends  may  not  be  observable  macroscopic- 
ally,  nor  have  scarcely  teratologic  significance;  the  psychic  develop- 
ment is  never  arrested,  only  distorted  or  manifested  in  a  perverse 
way  (as  transition  to  the  psychic  degenerations,  vide  page  35Ü). 


CHAPTER  I. 
Intellectual   Idiocy. 

Under  this  general  term  all  states  of  mental  weakness,  whether 
congenital  or  acquired  during  the  developmental  period  of  the  psychic 
organ,  are  grouped.  These  cases  of  psychic  insufficiency  present  a 
progressive  series  of  symptomatic  pictures  which  stretches  from 
states  of  mental  nullity  to  the  degrees  of  feeble-mindedness  which 
approach  a  state  of  normal  intellectual  development. 

As  a  subclass  of  idiocy,  states  of  congenital  mental  weakness  are 
to  be  separated  in  which  the  mental  disturbance,  as  a  result  of 
peculiar  injurious  causes,  is  accompanied  by  a  corresponding  degree 
of  bodily  degeneration.  Such  cases  are  called  cretinism.  They  con- 
stitute a  form  of  idiocy.  This  is  the  general  designation.  A  peculiar 
etiologic  variety  of  cretinism  is  the  so-called  Alpine  cretinism. 

The  causes  of  idiocy  may  be  active  during  fetal  life,  during  birth, 
or  during  the  years  from  birth  to  puberty.  Among  the  causes  which 
even  at  the  moment  of  conception  or  during  embryonic  life  may  be 
active  are,  first,  certain  factors  which  lie  in  the  generative  elements 
and  lead  to  malformation  of  the  brain  or  of  the  cranium.  These 
malformations  consist  of  abnormally  early  synostosis  of  the  cranial 
sutures,  with  consequent  inhibition  of  the  development  of  the  brain ; 
or  of  independent  arrest  of  development  of  this  organ,  or  of  a  single 
part  of  it  that  is  essential  for  the  activity  of  the  psychic  processes. 

Especially  important  factors  in  the  causation  of  idiocy  on  the 
side  of  progenitors,  as  has  been  shown  by  statistics,  are  epilepsy, 
brain  diseases  (especially  psychoses),  continued  intermarriage  of 
blood-relations,  and  drunkenness.  According  to  the  experience  of 
Euer  and  Flemming,  it  may  even  happen  that  idiots  are  begotten  by 
parents  in  nowise  burdened,  if  the  moment  of  conception  is  con- 
temporaneous with  intoxication. 

Influences  less  well  established  are  great  mental  exhaustion  in 
the  progenitors,  inanition  and  high  degree  of  anemia,  emotional 
excitement  of  the  mother  during  pregnancy,  and  physical  injury  to 


ARREST  OF  rSYCHlC  DEVELOPMENT.  ßll 

the  mother,  especially  traumatism  of  the  abdomen.  That  syphilis 
may  also  be  effectual  is  shown  by  a  case  reported  by  Guislain 
("  Lecons  Orales,"  ii,  page  93),  in  which  a  man  under  treatment  with 
mercury  for  syphilis  begot  a  child  that  was  weak-minded  from  birth, 
while  all  his  other  children,  before  and  after,  were  healthy  and 
normal  mentally. 

In  spite  of  such  causes  lying  in  the  generative  elements,  it  may 
happen  that  the  brain  diseases  resulting  from  them,  and  which  lead 
to  idiocy,  reach  their  development  only  after  birth,  or  from  the  third 
to  the  seventh  year. 

Besides  these  influences  affecting  the  embryo,  there  are  certain  telluric 
influences  which,  in  large  part,  cause  endemic  and  Alpine  cretinism.^  The  spe- 
cial injurious  influences  of  a  telluric  kind  are  not  yet  satisfactorily  under- 
stood. The  principal  regions  where  this  endemic  curse  exists  are  in  the  high 
mountains  of  the  earth  v/ith  their  connected  chains:  in  Europe,  in  the  Alps; 
in  Asia,  in  the  Himalayas;  in  South  America,  in  the  Cordilleras.  That  these 
injurious  influences  are  efl'ectual  during  fetal  life,  and  not  after  birth,  is  proved 
by  the  fact  that  cretinism  is  transmitted  to  descendants  even  when  the  child 
was  begotten  in  a  place  widely  separated  from  the  endemic  region  (in  a 
slighter  degree,  to  be  sure)  and  that  it  is  transmitted  to  following  generations, 
and  only  finally  after  a  long  period  of  separation  from  the  endemic  region,  and 
by  crossing  with  unaflfected  families,  gradually  do  the  last  traces  of  cretinism 
disappear. 

Race-crossing  alone  does  not  cause  cretinism  to  disappear.  In  order  to 
obtain  this  result  it  is  absolutely  necessary  that  the  family  leave  the  endemic 
region.  This  is  corroborated  by  the  fact  that  individuals  absolutely  healthy 
who  immigi'ate  into  an  endemic  region  may  procreate  cretins.  Moreover, 
high-grade  cretins  do  not  have  descendants;  for  the  men  are  almost  always 
impotent  and  the  women  commonly  sterile. 

Where  cretinism  is  endemic,  it  is  certainly  the  expression  of  degenerative 
factors,  signs  of  which  manifest  themselves  also  in  the  non-cretin  population 
by  a  shorter  average  period  of  life,  by  smaller  capacity  for  intellectual  and 
physical  work,  by  the  decrease  of  the  fecundity,  and  by  the  augmentation  ot 
the  percentage  of  deformities  and  mental  and  nervous  diseases   (Zillner). 

During  birth  traumatic  influences  may  affect  the  infantile  brain 
and  lead  to  idiocy;  for  example,  injuries  due  to  a  narrow  pelvis, 
forced  delivery  Mdth  forceps,  fall  on  the  head  in  precipitate  labor. 

In  the  vast  majority  of  cases  the  injurious  influences,  to  some  of 
which  we  have  already  alluded,  exercise  their  influence  first  during 
the  years  of  childhood.     They  are  extremely  numerous.     Head  in- 


^  The  cause  of  Alpine  and  sporadic  cretinism  is  defect  or  absence  of  the 
thyroid  gland.  The  causes  of  defect  or  absence  of  the  thyroid  gland  are 
various,  endemic  or  accidental.  Goiter  is  remarkably  frequent  in  mountainous 
regions. — Tkanslatob. 


612  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

juries  must  be  incntioned  here.  Thus,  Mitchell  {Edinburgh  Med- 
ical  Journal,  1866,  April,  page  933)  I'ound  that,  in  2  per  cent,  of 
all  the  idiots  in  Scothmd,  their  disease  was  ascribed  to  external 
injurious  influences,  among  which  head-injuries  took  the  most  prom- 
inent place.  Köstle  ("Endemic  Cretinism,"  page  95)  also  reports 
48  cas(?s  of  idiocy  in  children,  whose  trouble  was  ascribed  exclusively 
to  a  fall  on  the  head. 

Without  doubt  unsanitary  conditions  of  houses,  especially  in  the 
dwellings  of  the  proletariat  in  large  cities,  where  light  and  sun  are 
wanting,  with  uncleanliness  and  crowding,  may  cause  sporadic  idiocy 
and  cretinism.  Further  causes  are  hyperemia  of  the  brain  due  to 
wrapping  up  the  head,  sleeping  in  a  hot  oven,  and  abuse  of  opiates 
and  brandy  as  quieting  means  (Griesinger). 

To  these  may  be  added  lack  of  care,  uncleanliness  of  the  child's 
body,  insufficient  food,  exhaustion  of  the  infantile  organism  by  in- 
jurious influences  of  all  kinds,  and  acute  diseases,  especially  the  acute 
exanthemata  M'hich  cause  brain  complications;  and,  further,  epilepsy 
and  early  onanism.  In  hereditarily  tainted  individuals,  even  at  the 
time  of  puberty,  without  any  external  cause,  brain  disease  (hyperemia, 
inflammatory  edema?)  may  occur,  which  limits  the  further  develop- 
ment of  the  brain,  and  causes  a  regression  from  the  level  of  mental 
development  already  attained.  The  result  then  is  a  lasting  condition 
of  feeble-mindedness,  or  dementia. 

As  far  as  the  anatomico-pathologic  processes  lying  at  the  foundation  of 
idiocy  are  concerned,  it  may  be  said  in  general  that  they  are  seldom  acute, 
usually  chronic,  and  consist  of  congestive,  inflammatory,  or  other  nutritive 
disturbances  of  the  brain  and  tlie  membranes,  and  very  frequently  also  of  the 
cranium. 

No  special  alteration  of  the  central  organs  lies  at  the  basis  of  those 
conditions,  not  even  in  Alpine  cretinism;  but  it  may  be  said  in  general  that 
the  causes  of  cretinism  lie  primarily  in  the  anomalies  of  the  skull.' 

Macroscopically  as  the  causes  of  idiocy  we  find:  general  or  partial 
atrophy  of  the  brain  due  to  hyperemia,  inflammation,  softening,  meningeal 
extravasations,  hydro])s  of  the  arachnoid,  internal  hydrocephalus.  These 
hyperemias  are  not  infreciuently  the  result  of  caloric  influences  (lying  in  over- 
heated atmosphere,  -warm  rooms,  keeping  the  head  too  warm,  insolation),  or 
of  obstruction  to  respiration  and  circulation  due  to  diseases  of  the  respiratory 
or  circulatory  organs  (whooping-cough).  Meningeal  extravasations  occur 
during  birth  or  as  complications  in  acute  diseases. 

The  abnormalities  of  the  bones  of  the  skull  consist,  for  the  most  part, 
of  premature  synostoses.  The  microscopic  examination  of  the  brain  of  idiots 
has  disclosed:    shrinking  of  the  ganglion-cells  of  the  cortex,  with  clouding  of 


^Anomalies   of  the   skull,  etc.,  are  the  results,  and  not   the   causes,  of 
cretinism. — Tbanslatok. 


ARREST  OF  PSYCHIC  DEVELOPMENT.  CI 3 

the  interganglionic  masses,  and  obstruction  to  the  circulation  in  the  cortex 
due  to  obliteration  of  many  of  the  veins  into  which  the  capillary  vessels  im- 
mediately empty. 

When  these  vai-ious  macroscopic  and  microscopic  processes  are  carefully 
considered,  the  most  striking  things  found  in  tlie  brain  in  the  form  of  arrest 
of  development  or  as  results  of  earlier  disease  processes  are: — 

1.  Abnormal  smallness  of  the  brain  in  all  its  diameters.  Under  such 
circumstances  there  is  a  simple  arrest  of  development,  a  miniature  brain,  well 
proportioned  in  all  its  parts,  which,  however,  may  be  unequally  developed  in 
some  portions.  There  are  some  cases  in  which,  with  a  comparatively  good 
volume,  there  is  simplicity  and  poverty  of  convolutions.  The  cause  of  this 
arrest  of  growth  of  the  brain,  on  the  whole,  is  not  infrequently  early  primary 
synostosis,  but  there  are  other  cases  in  which  the  sutures  remain  open,  and  the 
cause  of  the  arrest  of  development  lies  in  the  brain  itself.  In  these  eases  the 
skull  is  often  abnormally  thick,  or  hydrocephalus  exists;  or  there  may  be 
sclerosis  of  the  brain.  In  general,  the  development  of  the  brain  and  the  de- 
velopment of  the  skull  are  only  in  subordinate  relation,  as  they  develop,  fur 
the  most  part,  independently. 

2.  Partial  arrests  of  development  of  the  brain.  The  arrest  may  affect 
the  anterior  or  the  posterior  lobe;  or  there  may  be  arrest  of  growth  of  one 
hemisphere,  as  a  result  of  unilateral  synostosis,  or  original  defective  develop- 
ment; or  of  encephalitis  and  focal  changes.  Other  findings  are  distortion  of 
the  medulla  oblongata,  and  unequal  size  and  asymmetry  of  portions  at  the 
base.  Sometimes  the  spinal  cord  is  implicated  in  this  way.  The  central  canal 
of  the  spinal  cord  may  also  remain  open. 

3.  So-called  eases  of  porencephaly:  i.e.,  cases  in  which  portions,  more  or 
less  extensive,  of  the  convolutions  and  the  centrum  semi-ovale  are  wanting,  so 
that  there  is  a  free  opening  into  the  ventricles.  These  spaces  are  then  filled 
with  abundant  serum,  forming  a  bladder;  or  a  meshwork  of  the  internal  mem- 
branes incloses  it.  Sometimes  the  skull  protrudes  at  such  a  point.  This  con- 
dition does  not  seem  to  be  the  result  of  arrest  of  development,  but  of  a  de- 
structive disease  (usually  fetal).  As  a  rule,  in  such  cases  there  is  paralysis 
and  contracture  of  the  opposite  side  of  the  body. 

4.  Absence  of  portions  of  the  brain,  as  of  the  cerebellum,  the  pineal 
gland,  or  the  corpus  callosum. 

5.  A  very  frequent  finding  is  chronic  congenital  hydrocephalus,  or  hydro- 
cephalus of  very  early  origin,  especially  with  open  fontanels  and  macro- 
cephaly.  It  is  usually  primary,  sometimes  secondary,  and  due  to  atrophy  of 
single  portions  of  the  brain. 

6.  Encephalitic  processes,  focal  or  diffuse,  especially  with  consecutive 
cerebral  sclerosis  and  atrophy  of  the  affected  parts.  These  processes  occur 
during  fetal  life  and  up  to  five  years  after  birth.  Idiocy,  tmder  such  circum- 
stances, is  usually  accompanied  by  hemiplegia,  contracture,  and  also  often  by 
epilepsy  (Griesinger). 

In  those  frequent  cases  in  which  a  child,  up  to  this  time  well  developed, 
during  dentition  develops  fever,  has  convulsions,  becomes  delirious,  and  re- 
covers quickly,  but  becomes  an  idiot,  the  causes  to  be  considered  especially 
are:— 

fa)  Congestive  or  inflammatory  processes  aft'ecting  the  cerebral  mem- 
branes, as  result  of  which  hydrocephalus  easily  arises. 


614  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

(b)  Encephalitis,  which,  after  the  subsidence  of  the  acute  brain  dis- 
ease, is  followed  by  arrest  of  development  of  the  brain  in  the  parts  aflfected. 
Such  processes  are  to  be  assumed,  especially  when  one  side  of  the  body  ceases 
to  grow,  or  when  unilateral  spasm,  paralysis,  or  contracture  comes  on 
(Gritsinger). 

7.  There  are  infrequent  cases  in  which  the  brain  is  hypertrophied  »71  ioto 
(Virchow,  Baillarger,  Robin). 

8.  The  most  infrequent  conditions  are  remarkable  anomalies  in  richness 
of  gray  substance,  with  even  heterotopic  development  of  it  in  places  where  it  is 
not  normally  found;  as,  for  example,  in  the  white  substance  of  the  hemispheres. 

The  anomalies  which  concern  the  skull  are  either  secondary,  as  already 
indicated,  or  primary.  The  former  are  due  to  arrest  of  development  of  the 
brain  as  a  whole  or  in  part.  As  a  result  of  this  there  is  corresponding  early 
synostosis  of  tlie  skull,  or  ossificaticn,  as  a  result  of  which  general  or  partial 
arrest  of  development  of  the  skull  occurs. 

The  primary  cranial  anomalies  wliioh  principally  interest  us  here  have  to 
do  with  the  vertex  or  the  base  of  the  skull  or  with  both.  They  are  founded 
upon  an  arrest  of  growth  of  the  bones,  as  a  result  of  inflammatory  processes 
affecting  nutrition  at  the  sutures  (Virchow,  Welker),  with  the  premature 
synostosis  which  results ;  or  due  to  the  insufRciency  of  nutrition  of  the  cranial 
bones  as  a  result  of  precocious  obliteration  of  their  vessels  (Gudden).  L. 
!Meyer  rightly  makes  rachitic  processes  responsible  for  a  part  of  these  anom- 
alies of  the  skull.  Out  of  this  arise  numerous  distortions  of  the  cranium  and 
malformations,  vnth  or  without  synostosis  of  the  sutures,  according  to  the 
nature  of  the  cause  (dolicho-,  lepto-,  spheno-,  klino-,  brachy-,  or  oxy- cephaly). 

If  the  arrest  of  development  of  the  cranium  is  uniform  and  general, 
simple  microcephaly  results,  the  skull  being  well  proportioned.  If,  on  the 
other  hand,  it  affects  the  vertex  and  not  the  base,  there  results  a  very  par- 
ticular type  of  head,  body,  and  mind — the  so-called  Aztec  type.  Such  indi- 
viduals are  microcephalic  and  dwarfish,  but  Avell  proportioned,  and  even 
elegantly  formed.  The  root  of  the  nose,  as  a  rule,  is  prominent,  so  that  the 
brow  is  on  a  plane  mth  the  nose  (Griesinger). 

Gratiolet  has  examined  a  few  cases  in  which  the  skull  was  small,  with 
very  thick  bones  and  synostosis  of  the  vertex,  but  the  base  was  but  slightly 
ossified,  being  almost  entirely  cartilaginous.  The  pars  petrosa  and  ethmoid 
were  larger  than  normal,  and  the  space  containing  the  cerebellum  was  ex- 
tremely large  in  all  directions.  In  consonance  with  this,  the  cerebellum, 
medulla  oblongata,  and  spinal  cord  were  extremely  Avell  deA'eloped,  as  well  as 
the  sense-organs  and  their  nerves,  while  the  superficial  portions  of  the  cere- 
brum in  some  cases  showed  fewer  convolutions  than  the  orang-outang. 

The  enormous  development  of  the  parts  of  the  brnin  serving  motor 
fimctions,  in  contrast  with  the  lack  of  development  of  the  psyeliic  centers,  due 
to  compensatory  enlargement  of  the  base  of  the  skull,  corresponded  with  the 
mental  condition.  Such  individuals  are  extremely  lively,  moving  like  "birds, 
and  with  movements  well  co-ordinated.  They  are  gay,  excitable,  curious  but 
moody,  almost  devoid  of  attention,  and  very  weak-minded,  even  though  they 
speak  well." 

Griesinger  likens  them  to  birds;  and  their  narrow,  low,  short  heads; 
their  pointed  noses,  with  wide,  high  roots;  and  their  nervous  eyes  recall  very 
strikingly  the  physiognomy  of  a  bird. 


AUREST  OF  PSYCHIC  DEVELOPMENT.  615 

The  opposite  of  this  condition  is  the  basilar  synostotic  form  due  to  pri- 
mary premature  ossification  of  the  bones  at  the  base,  as  it  occurs  mainly,  but 
not  exclusively,  in  endemic  and  Alpine  cretinism.  As  is  well  known,  during 
fetal  life  there  are  three  cartilaginous  discs,  between  the  anterior  and  pos- 
terior sphenoids  and  between  the  sphenoid  bone  and  the  basilar.  The  fii'st 
two  are  quite  insignificant  and  ossify  normally  shortly  after  birth.  Tlio 
cartilage  which  lies  between  the  sphenoid  and  the  basilar  ossifies  only  at  the 
age  of  15,  and  in  certain  individuals  even  as  late  as  tlie  age  of  20;  so  that 
the  base  of  the  skull  has  at  least  15  years  of  growth.  If  this  ossification 
takes  place  too  early,  it  causes  a  form  which  ordinarily  is  normal  during  the 
first  half  of  the  period  of  fetal  life,  and  which  produces  the  external  form  of 
the  cretinous  skull:  i.e.,  a  more  pronounced  flexion  of  the  base  of  the  cranium 
toward  the  vertex,  a  narrow  angle  of  union  of  the  sphenoid  and  the  basilar 
process  (sphenoidal  kyphosis),  and  a  more  pronounced  clivus. 

This  gives  rise  to  a  very  characteristic  physiognomy,  quite  the  opposite 
of  the  Aztec  type ;  namely:  prominent  nose;  deep,  broad,  nasal  root;  widely 
separated  eyes;  broad,  shallow  orbits;  prominent  cheek  bones  and  jaw 
(prognathism). 

A  further  result  is  flatness  of  the  palate,  narrowness  of  the  great  wings 
of  the  sphenoid,  leading  to  narrowness  of  the  middle  cranial  fossa,  which  pre- 
vents development  of  the  fore-  and  mid-  brain  (Griesinger). 

Tribasilar  synostosis  is  thus  the  anatomic  point  of  departure  of  this 
special  form  of  cretinism,  especially  Alpine  cretinism.  However,  this  is  not 
the  only  cranial  deformity  that  may  cause  Alpine  cretinism.  All  other 
possible  forms  may  bring  about  the  same  result.  Along  with  these  ari'ests 
there  may  be  other  anomalies  of  the  skeleton,  as  Avell  as  other  degenerative 
aff"ections  of  other  parts  of  the  body.  Sometimes  the  individual  is  a  dwarf 
as  a  result  of  premature  ossification  of  the  cartilages  of  the  epiphyses. 

As  a  rule,  the  head  is  too  large  in  proportion  to  the  body  in  general. 
The  face  has  a  senile  expression.  The  head  is  placed  on  a  small,  medium,  or 
even  infantile  body.  With  this  the  lips  are  thick,  the  eyelids  wrinkled,  the 
nose  receding,  and  broad  and  deep  at  its  base.  The  body  is  pufl'ed  and  wrinkled 
as  a  result  of  hypertrophy  of  the  skin  and  adipose  tissue.  With  this  there 
is  a  goitrous  degeneration  of  the  thyroid  gland.  In  contrast  with  the  Aztec 
type,  the  mentality  is  apathetic  and  torpid,  intellectual  life  may  be  reduced 
to  zero,  and  speech  may  be  impossible. 

The  clinical  consideration  of  idiots  and  cretins  must  be,  in  the 
first  place,  with  reference  to  the  essential  and  important  functional 
disturbances  of  mind.  Classification  in  accordance  with  the  degree 
of  mental  infirmity  in  these  conditions  that  vary  infinitely  is  difficult. 

On  the  whole,  we  may  divide  them  into  idiots  and  half -idiots  (imbeciles), 
complete  and  half-  cretins.  An  attempt  at  further  diflferentiation  may  be 
made  in  accordance  with  the  condition  of  speech  as  the  most  important 
criterion  of  mental  development  and  capability  of  development.  Thus  Ki-auss 
distinguishes : — 

1.  The  profound  degree  of  idiocy:  a  state  of  absence  of  the  senses  in 
which  speech  is  entirely  wanting  or  reduced  to  mere  inarticulate  sounds. 


C16  SPECIAL  PATHOLOGY  A^T)  THEEAPY  OF  INSANITY. 

2.  Idiocy:  in  this  condition  tho  speech  is  but  little  developed,  the  vocab- 
ulary limited  to  words  related  to  the  sphere  of  the  most  primitive  material 
needs. 

3.  Mental  dullness:  speech  in  tliis  condition  is  no  longer  fragmentary, 
simple  formation  of  sentences  being  possible,  but  it  is  quantitatively  and 
qualitatively  at  a  childish  level  and  limited  to  sensual  ideas. 

4.  Imbecility:  in  this  condition  speech  is  more  elaborate  and  approaclies 
tliat  of  normal  individuals,  but  it  is  jjodr  and  full  uf  defects  as  soon  as  it  is 
concerned  with  abstract  ideas. 

For  our  clinical  ]nirpo<.c  it  i>;  sufliciciit  to  distiiiiiuisli  two  dcgTCOs, 
namely:  idiocy,  in  which  the  format it)n  of  abstract  ideas  (concepts 
and  judgments)  and  a  corresponding  vocabulary  are  wanting;  and 
imbecility,  in  which  this  faculty  is  present,  though  in  limited  degree, 
never  attaining  the  height  and  extent  of  the  average  normal  in- 
dividual. 

Psychic  S Y:\rrTOMS. — At  the  lowest  level  of  idiocy,  mental  ]iroc- 
esses  are  almost  entirely  wanting.  Sense-impressions  are  limited  to 
objects  which  satisfy  hunger,  and  only  the  need  for  satisfaction  of 
hunger  causes  such  low  organizations  to  make  instinctive  movements 
for  the  fulfillment  of  this  purpose.  The  sexual  instinct  is  wanting 
or  present  only  in  slight  degree.  The  satisfaction  of  the  desire  for 
food  is  the  point  around  which  all  psychic  processes  are  centered. 
Instead  of  conscious  activity  with  an  idea  of  a  purpose,  there  is 
merely  instinctive  movement  induced  by  external  stimuli,  or  by  an 
intense  internal  need,  and  which,  at  most,  may  be  mechanically 
directed  by  training  and  practice. 

The  idiot  remains  lazily  quiet  because  motives  for  movement  are 
wanting.  In  the  most  profound  degree  of  this  condition,  that  of 
apathetic  idiocy  where  there  are  no  ideas,  the  motor  side  of  life  is 
limited  to  purely  reflex  movement  and  automatic  acts,  with,  perhaps, 
at  most,  certain  instinctive  movements  and  instinctive  desire  for 
food.  In  the  instinctive  satisfaction  of  the  latter,  however,  the  idiot 
is  not  even  in  the  condition  of  an  animal  able  to  seek  his  food.  With- 
out choice  he  puts  everything  in  his  mouth  that  comes  to  his  hand. 
Such  low  organizations  are  as  helpless  as  newborn  children.  They 
would  starve  if  they  were  not  cared  for. 

The  absence  of  psychic  stimuli  lends  also  to  the  attitude  of  the 
higher  idiot  characteristic  features  of  relaxation  and  lack  of  energy 
which  are  also,  in  part,  due  to  the  fact  that  the  extensor  muscles  are 
less  innervated  than  in  normal  individuals.  Too,  even  when  paral- 
ysis and  muscular  insufficiency  are  absent,  gait  and  attitude  present 
something  heavy,  awkward,  and  uncertain.  ISTumerous  as  the  degrees 
of  idiocy  may  be,  the  limit  that  separates  it  from  imbecility  always 


AEREST  OF  PSYCHIC  DEVELOPMENT.  617 

consists  of  this :  that  its  defective  concepts  cannot  be  separated  from 
the  sensory  elements  nor  utilized  in  the  formation  of  abstract  com- 
prehensible ideas,  judgments,  and  notions. 

Too,  the  reproduction  of  any  idea  is  incomplete,  only  resulting 
from  external  stimuli  or  some  intense  internal  need.  The  activity 
of  ideas  is  thus  purely  mechanical  as  originally  formed.  The  com- 
plete idiot  is  incapable  of  anything  like  emotional  activity;  he  has 
no  compassion,  no  social  sentiment;  he  does  not  even  feel  a  need  of 
companions.  He  enjoys  the  benefits  of  social  life  without  having  any 
ethic  comprehension  of  them.  Keaction  is  possible  in  only  one 
direction,  namely:  when  his  ego  feels  a  need  or  is  hurt.  Under  such 
circumstances  he  reacts  with  anger  which  may  become  extremely 
violent  and  be  manifested  with  a  brutality  that  surpasses  all  bounds. 
Such  explosions  have  the  features  of  paroxysms  of  rage  in  which 
consciousness  is  entirely  wanting  and  of  which  the  individual  has 
no  memory.  Sometimes  also  there  are  spontaneous  or  even  periodic 
outbursts  of  anger  and  mania  under  the  influence  of  fluxionary  hyper- 
emia of  the  brain,  especially  when  the  skull  is  small. 

In  imbeciles  there  are  also  insufficiencies  of  psychic  activit3\ 
The  sensorial  activity  shows  defects  in  that  in  imbeciles  the  per- 
ception of  sense-impressions  is  lower,  and  many  sensory  perceptions 
escape  them.  Necessarily  there  is  therefore  poverty  of  ideas,  espe- 
cially since  the  sensory  impressions  registered  are  not  completely 
elaborated  as  in  the  normal  individual;  for  association  and  repro- 
duction are  slower  and  defective. 

Thus  the  formation  of  abstract  ideas  and  judgments  is  imperfect, 
and  judgment  of  abstract  things  is  one-sided,  indistinct,  and  largely 
influenced  by  the  authority  of  others.  The  feeble-minded  are  credu- 
lous, easily  duped,  have  no  opinions  of  their  own,  and  depend  upon 
others.  The  inner  nature  and  the  finer  relations  of  things  escape  them, 
and  they  are  likewise  incapable,  when  once  the  real  point  of  the  matter 
has  been  taught  them,  to  give  it  the  right  word.  The  vocabulary  is 
always  poor  the  moment  abstract  ideas,  are  concerned,  while  in  the 
sensual  sphere  they  are  capable  of  expressing  themselves  sufficiently. 

The  inner  impulse  of  the  normal  individual  to  look  for  the  foun- 
dation and  nature  of  things  and  their  changes  is  absolutely  wanting 
in  the  imbecile.  He  accepts  things  as  they  are,  or  manifests  but  a 
kind  of  stupid  curiosity.  Higher  mental  interests  and  purposeful 
activity  are  foreign  to  him. 

In  the  gratification  of  the  ordinary  material  needs  of  life  his 
being  is  satisfied;  he  has  no  time  and  less  desire  to  occupy  himself 
with  abstract  things,  which  weary  him  and  cost  him  too  much,  effort. 


618  SPECIAL  PATHOLOGY  AND  THERAPY  OF  INSANITY. 

This  incapability  in  the  intellectual  domain  manifests  itself  also  in 
ethic  feeling.  The  feeble-minded  individual  is  necessarily  an  ego- 
tist; he  overestimates  his  own  person  and  his  activities,  as  a  result 
of  which  he  becomes  the  object  of  derision  and  ridicule.  The  welfare 
of  humanity  does  not  touch  him;  only  interference  with  his  own 
personality  induces  stormy  outbursts  which  then  easily  pass  beyond 
normal  limits.  His  pleasurable  emotions  easily  pass  into  foolish 
excess,  his  depressive  feelings  into  raving  or  confusion ;  and  these  are 
induced  with  especial  ease  as  a  result  of  fear,  and  then  degenerate 
into  terror. 

The  imbecile  may  be  a  useful  member  of  society;  for  he  may 
acquire  some  habitual  occupation,  especially  if  it  be  a  mechanical  one; 
and,  once  acquired,  he  carries  it  out  well,  because  he  gives  his  entire 
attention  to  it.  But  his  activity  is  mechanical,  without  capability  of 
alteration  or  of  combining  or  producing  anything  new.  He  has  no 
personal  and  new  ideas,  but  lives  upon  knowledge  and  experiences  that 
he  has  acquired  at  great  cost.  Necessarily,  as  a  result  of  this  limited 
activity,  spontaneity  and  purposeful  striving,  as  seen  in  the  normal 
individual,  are  wanting.  Slight  hindrance  is  sufficient  to  perplex  him, 
for  he  is  not  able  to  surmount  it;  and  being  unable  to  think  for  him- 
self, it  suffices  often  to  advise  against  a  thing  to  arrest  his  voluntary 
efforts;  just  as,  on  the  other  hand,  the  authority  of  another  may 
easily  induce  him  to  do  his  best  or  to  commit  senseless  acts. 

Esthetic  and  superior  moral  judgments  are  scarcely  possible  to 
the  imbecile.  In  their  place  he  possesses  the  moral  judgments  of 
others  which  he  has  simply  appropriated  in  memory  and  reproduces 
automatically.  Almost  all  his  esthetic,  religious  ideas  and  judgments 
are  but  efforts  of  memory  and  reminiscences  of  employment,  which 
as  time  goes  on  are  reproduced  more  and  more  imperfectly  and 
slowly.  However,  the  sentiment  of  justice  and  of  duty  may  be  very 
well  developed,  but  it  never  has  the  profound  basis  of  sentiment  and 
ethic  opinion  so  solidly  rooted  in  the  character  of  the  normal  indi- 
vidual. It  is  always  a  semiconscious  movement,  an  inspiration  of 
consciousness,  which  utilizes  the  moral  judgment  of  others.  This  is 
why,  when  an  imbecile  repents  of  an  illegal  act  he  may  have  com- 
mitted, the  repentance  is  merely  superficial. 

An  interesting  phenomenon  in  a  certain  class  of  idiots  is  the 
existence  of  isolated,  instinctive  faculties,  comparable  to  the  instinct 
of  certain  animals,  for  certain  kinds  of  work,  or  for  certain  artistic 
efforts,  which  are  the  more  astounding  because  the  rest  of  the  intel- 
lectual life  is  so  inferior.  Such  capabilities  are  observed  especially  in 
the  form  of  remarkable  talents  in  the  direction  of  mechanics,  drawing, 


ARREST  OF  PSYCHIC  DEVELOPMENT.  619 

and  music.  There  are  other  isolated  cases  in  which  there  is  an  aston- 
ishing memory  for  words  or  for  figures.  Such  isolated  endowments 
are  never  met  in  accidental  idiocy,  but  only  in  cases  of  idiocy  due  to 
hereditary  degenerative  causes. 

Somatic  Symptoms. — With  these  disturbances  of  the  psycl)ic 
functions,  in  the  larger  number  of  cases  there  are  other  functional 
disturbances  dependent  upon  lesions  of  the  central  organ.  In  tlie 
domain  of  the  higher  senses  there  is  frequently  amblyopia  due  to 
atrophy  of  the  oiDtic  nerves  or  retinitis  pigmentosa,  deafness,  and  de- 
fects of  smell  and  taste  (in  some  of  these  cases  the  olfactory  lobe  has 
been  found  atrophied).  The  cutaneous  sensibility  is  not  infrequently 
dulled  or  there  may  be  anesthesia.  Strabismus  is  frequent,  less  fre- 
quently due  to  spasm  than  to  paralysis  of  the  ocular  muscles.  Stut- 
tering is  also  frequent. 

Num.erous  central  motor  disturbances  are  observed  in  the  ex- 
tremities : — 

(a)  Spasm,  sometimes  partial  and  limited  to  toes,  arm,  or  leg; 
sometimes  general  and  choreiform.  Athetosis  also  occurs.  Epilepti- 
form spasms  are  frequent.  These  may  have  a  double  significance: 
either  they  are  co-ordinated  symptoms  of  the  mental  infirmity,  and 
due  to  the  same  anatomic  causes;  or  the  epilepsy  is  the  primary  dis- 
ease and  has  induced  the  idiocy. 

(h)  From  contractures  there  may  be  spastic  club-foot,  caput 
obstipum,  etc.  Symptoms  of  spastic  spinal  paralysis  are  not  infre- 
quent, and  are  usually  due  to  polioencephalitis  (porencephaly). 

(c)  Paralytic  conditions  are  frequent.  Many  high-grade  idiots 
can  neither  stand  nor  walk.  In  others  there  is  difficulty  of  maintain- 
ing equilibrium  in  walking.  ISi'ot  infrequently  there  are  the  remains 
of  anterior  poliomyelitis  in  the  form  of  paralysis  with  muscular 
atrophy,  and  absence  of  reflexes  and  electric  excitability.  Spastic 
paralysis  due  to  hydrocephalus  is  less  frequent. 

(d)  Finally  there  remains  to  be  mentioned  automatic  instinctive 
movements,  as  well  as  choreiform  disturbances,  which,  according  to 
Schule,  are  to  be  regarded  as  the  expression  of  direct  processes  of 
excitation  affecting  the  psychomotor  centers  in  a  state  of  incomplete 
development. 

There  are  also  marked  disturbances  of  the  sexual  functions  in 
idiots.  In  high-grade  idiots  it  is  entirely  wanting.  The  genitals  are 
-frequently  small  and  distorted.     The  menses  come  on  late  or  not  at  all. 

There  is  impotence  or  sterility.  Even  in  idiots  of  moderate 
grade  the  sexual  instinct  is  weakly  developed.  Sometimes  stormy 
expression  of  it  is  observed.    Onanism  occurs  in  the  milder  cases. 


630  SPECIAL  PATHOLOGY  AND  THEPAPY  OF  INSANITY. 

Trophic  anomalies  due  to  central  causes  are:  dwarfism;  a  thick, 
fleshy  tongue;  tliick  lips,  and  bad  teeth  that  soon  decay,  seen,  as  a 
rule,  in  the  endemic  form. 

Upon  the  basis  of  arrest  of  mental  development  tlie  most  varied 
psychoses  may  occur.  In  consonance  with  the  low  mental  state  in 
idiot«,  I  have  seen  furious  mania.  In  imbeciles  I  have  seen  the  various 
psychoses  hs  they  occur  in  fully  developed  individuals,  with  the  excep- 
tion of  the  insanity  of  imperative  ideas.  Dementia  paralytica  is  not 
infrequent.  Melancholia  is  frequent,  especially  in  the  form  of  a  psy- 
cliosis  of  fright.  Slight  causes — as,  for  example,  death  of  a  domestic 
animal  or  a  severe  scolding — may  induce  it.  The  direction  of  melan- 
cholic ideas  is  very  frequently  that  of  religious  or  demonouumiac  delu- 
sions. Panphobia,  especially  on  entrance  into  a  hospital  or  asylum, 
is  quite  usual.  These  feeble-minded  melancholies  are  difficult  to 
quiet  and  do  not  heai-  isolation  well;  tlierefore  it  should  be  avoided 
as  much  as  possible.  Owing  to  the  poverty  of  the  mind,  the  psychoses 
with  systematized  delusions  (melancholia,  paranoia)  present  but 
slight  elaboration  clinically ;  and,  besides,  these  imbeciles  do  not 
possess  the  necessary  vocabulary  to  express  satisfactorily  their  state 
of  mind.  Psychoses  in  imbeciles  disappear  more  slowly  and  with 
greater  difficulty  than  in  fully  developed  individuals.  In  its  organic 
as  well  as  its  psychologic  relations  the  psychosis  is  more  difficult  to 
overcome,  and  mental  treatment  has  a  narrower  space  for  activity. 
In  any  event,  the  prognosis  is  graver.  If  the  disease  be  overcome,  then 
homesicloiess  that  comes  on  during  convalescence  often  requires  early 
discharge — the  least  of  two  evils. 

Course  and  Prognosis. — AVitJi  reference  to  the  course,  owing 
to  the  variety  of  the  anatomic  processes  which  lie  at  the  foundation 
of  idiocy,  little  can  be  said  in  general.  The  processes  that  arise 
before  birth  or  in  the  first  years  of  life  are  frequently  arrested  and 
leave  behind  stationary  states  of  idiocy.  When  idiocy  develops  out 
of  epilepsy  or  hydrocephalus  it  frequently  has  a  progressive  course, 
and  the  single  series  of  epileptic  attacks  or  the  effects  of  inflamma- 
tory hyperemia  form  the  steps  by  which  the  mind  descends  to  com- 
plete destruction. 

Earely  the  causal  cerebral  disease  leads  directly  to  death,  as 
in  the  case  of  increase  of  hydrocephalus,  acute  hyperemias,  cerebral 
atrophy,  meningitis,  etc. ;  and  idiots  in  general  do  not  live  to  a  great 
age  because  the  brain  is  a  locus  minoris,  and  in  general  the  physical 
resistive  power  is  less  than  in  those  not  afflicted  with  this  infirmity. 

Cases  of  endemic  cretinism  are  most  apt  to  reach  an  advanced 
age,  but  examples  of  cretins  GO  years  old  are  rare.     Sometimes  a 


ARREST  OF  PSYCHIC  DEVEL0PM15NT.  621 

lasting  improvemcnt  of  the  malady  occurs.  Under  such  circum- 
stances we  have  to  deal  with  mild  cases  due  to  anemia,  or  exhaustion 
due  to  mental  and  physical  strain,  or  masturbation. 

Treatment. — Cure  of  idiocy  is  a  priori  imposHil)lo,  since  hero 
we  have  to  deal,  as  a  rule,  with  brain  diseases  that  have  run  their 
course  and  come  under  treatment  too  late.  Only  in  rare  cases,  when 
the  malady  depends  upon  constitutional  syphilis  or  epilepsy,  or  is  the 
expression  of  functional  exhaustion  or  due  to  palpable  cerebral  trouble 
in  its  beginning,  can  there  be  any  question  of  an  attempt  at  cure. 
Under  such  circumstances  hygienic  and  medical  means  may  come  in 
play.  Attempts  to  improve  hydrocephalic  idiocy  by  iodides  have  led 
to  no  result. 

Naturally  in  the  care  of  children  all  the  etiologic  influences  are 
to  be  taken  into  consideration  in  the  interest  of  prophyhixis.  Proph- 
ylaxis holds  out  the  most  hope  in  cases  of  endemic  cretinism.^ 
With  removal  from  the  endemic  region,  which  has  the  greatest  efl'ect 
upon  the  descendants,  but  which  is  only  seldom  possible,  the  task  is 
to  improve  the  telluric,  atmospheric,  and  hygienic  conditions  and 
thus  remove  the  causes  of  the  general  degeneration.  In  fact,  im- 
provement in  the  education  of  the  people,  greater  cleanliness,  drain- 
ing of  certain  regions,  etc.,  have  been  attended  with  considerable 
success. 

In  the  confirmed  case  of  idiocy,  the  object,  as  a  rule,  is  to  edu- 
cate by  methodic  pedagogic  training  the  existing  elements  of  the 
mind,  in  order  to  render  the  individuals  capable  of  mental  and  social 
existence ;  for  the  attainment  of  this  object  is  a  great  benefit  to  society, 
the  family,  and  the  individual.  This  becomes  the  task  of  institutions 
for  the  feeble-minded,  which  already  respond  to  this  public  need  in 
a  most  worthy  manner. 


CHAPTER  II. 
Moral  Idiocy  (Moral  Insanity). 

There  are  individuals  who,  though  reared  in  the  surroundings 
of  higher  civilization  and  given  every  occasion  to  profit  by  its  blessings, 
unlike  the  normal  individual  have  not  acquired  ethic  ideas  (religious 
and  esthetic)  ;  or,  if  acquired,  they  have  not  the  power  to  use  them  in 
the  formation  of.  moral  judgments  and  notions,  or  to  employ  them 
as  the  motive  or  countermotive  of  action.     A  brain  wanting  in  this 


^The  administration  of  thyroid  extract  is  of  the  greatest  utility  in  cre- 
tinism due  to  absence  of  the  thyroid  gland. — Tkanslatob. 


622  SPECIAL  TATHOLOGY  AND  THERArY  OF  INSANITY. 

capability  at  the  present  level  of  civilization  may  be  regarded  as 
inferior  ah  origine — defective;  and  such  a  view  of  the  nature  of  this 
condition  is  decidedly  justified  by  the  fact  that,  notwithstanding  all 
efforts  of  an  educational  kind,  either  in  the  family  or  at  school,  as  well 
as  all  kinds  of  unpleasant  experiences  which  the  individual  thus  or- 
ganized must  undergo  in  later  life,  it  is  impossible  to  influence  favor- 
ably his  ethic  feeling  and  conduct. 

The  cause  of  this  condition  is  organic,  and  in  such  congenitally 
defective  cases  found  in  hereditary  conditions,  among  which  the  most 
important  are  insanity,  drunkenness,  and  epilepsy  in  ancestry. 

In  contrast  with  these  congenital  cases  of  moral  idiocy,  and 
analogous  to  intellectual  idiocy,  there  is  a  similar  state  observed  in 
individuals  that  were  formerly  normal  and  in  whom  the  defect  is 
acquired  (comp,  page  55).  Under  such  circumstances  it  is  due 
to  grave  injury  or  degenerative  processes  affecting  the  brain,  and 
occurs  partly  as  a  prodromal  manifestation,  partly  as  an  accompani- 
ment of  them. 

The  causal  conditions  of  acquired  moral  defect  are  anatomic  and 
functional  brain  changes  as  they  occur  after  severe  head  injuries, 
apoplexies,  senile  involution  of  the  brain,  dementia  paralytica, 
drunkenness,  and  grave  constitutional  neuroses  (epilepsy,  hysteria).. 

Moral  insanity  affects  the  innermost  nucleus  of  the  individuality 
in  its  emotional,  ethic,  and  moral  relations.  Since  it  leaves  thought 
almost  unaffected, — the  capability  of  intellectual  judgment  as  to  what 
is  useful  and  injurious, — it  makes  possible  logical  judgment,  which 
conceals  the  defect  in  all  moral  jiidginent  and  ethic  feeling,  and 
this  causes  those  afflicted  with  moral  insanity  to  appear  clinically,  if 
not  ethically,  in  the  role  of  immoral  or  even  criminal  individuals. 

Like  Stolz,  Regiomontanus,  in  1513.  expressed  the  idea  that  there 
were  wicked,  immoral  men  Avho  were  not  responsible  for  their  wick- 
edness and  yet  were  hanged  by  the  judges.  What  the  investigator 
of  the  sixteenth  century  attributed  to  the  influence  of  the  stars  (born 
under  the  sign  of  Venus)  we  now  attempt  to  explain  by  abnormal 
relations  of  organization  in  the  individual.  In  Germany,  Grohmann 
(1819)  was  probably  the  first  to  recognize  ethic  degeneration  as  the 
result  of  organic  causes,  and  name  it  congenital  moral  insanity,  or 
moral  idiocy.  In  1842  Prichard  made  one  of  the  first  attempts  to 
describe  and  limit  the  clinical  picture  of  the  disease.  The  etiologic 
significance  of  the  abnormal  condition  as  degenerative  and  mainly 
hereditary  was  taught  by  Morel.  The  clinical  investigations  of 
Brierre,  Falret,  Solbrig,  and  others  have  brought  moral  insanity  into 
scientific  recognition. 


ARREST  OF  PSYCHIC  DEVELOPMENT.  ß23 

When  the  attempt  to  sketch  the  clinical  marks  of  this  peculiar 
defective  condition  is  made,  the  most  striking  manifestation,  and  that 
which  gives  it  its  autonomy,  is  more  or  less  complete  moral  insensi- 
bility and  absence  of  moral  judgment  and  ethic  notions,  in  place  of 
which  purely  logical  judgments  with  regard  to  what  is  useful  an^l 
injurious  are  found.  Of  course,  the  laws  of  morality  may  be  learned 
and  reproduced  mnemonically ;  but  if  they  enter  consciousness  they 
remain  uncolored  by  feeling  and  affects  and  are  dead  ideas, — useless 
ballast  in  the  consciousness  of  these  defective  individuals,  who  thus 
are  unable  to  find  a  motive  or  counterraotive  for  their  actions.    . 

To  this  moral  color-blindness,  this  insanity  of  altruistic  feeling 
(Schule),  civilization  and  moral  and  public  order  appear  to  be  only 
an  embarrassing  obstacle  for  egotistic  sentiment  and  effort:  a  condi- 
tion which  fatally  leads  to  negation  and  even  to  violation  of  the 
rights  of  others. 

Without  interest  in  all  that  is  noble  and  beautiful,  apathetic 
toward  all  movements  of  the  heart,  these  miserable,  disinherited  in- 
dividuals appear  to  be  strange  on  account  of  their  want  of  filial  love 
and  affection  for  their  relatives,  and  on  account  of  their  lack  of  all 
social  instincts,  their  coldness  of  heart,  their  indifference  to  the  lot 
of  their  nearest  relatives,  and  their  want  of  interest  in  all  the  ques- 
tions of  social  life.  JSTaturally  they  are  insensible  to  the  moral  ap- 
preciation or  blame  of  others;  they  have  no  scruples  of  conscience 
or  repentance.  They  do  not  understand  conventionalities.  Law  has 
for  them  only  the  significance  of  a  police  ordinance,  and  the  gravest 
crime,  from  their  particular  and  inferior  point  of  view,  is  a  simple 
infraction  of  a  police  regulation.  If  they  come  in  conflict  with  an 
individual  or  with  society,  their  simple  coldness  of  heart  and  negation 
give  place  to  hatred,  envy,  rancor,  and,  owing  to  their  state  of  moral 
idiocy,  their  brutality  and  recklessness  know  no  baunds. 

The  ethic  defect  in  these  individuals  of  inferior  organization 
in  the  end  renders  them  incapable  of  maintaining  a  place  in  society, 
and  makes  of  them  candidates  for  houses  of  correction,  prisons,  and 
hospitals  for  the  insane.  They  do  not  arrive  at  these  places  of  de- 
tention until  as  children  they  have  been  the  terror  of  their  parents 
and  teachers  on  account  of  their  laziness,  mendacit}^  and  villainy. 
More  mature,  they  are  the  disgrace  of  the  family  and  the  plague  of 
communities  and  authorities  on  account  of  their  tendency  to  vaga- 
bondage, dissipation,  excesses,  and  theft;  and  finally  they  become 
the  most  unmanageable  in  asylums  or  the  most  incorrigible  in  prisons. 

With  this  absence  of  ethic  altruistic  feeling,  and  the  egotism 
necessarily  arising  out  of  it,  there  is  a  formal  affective  disturbance,  a 


624  SPECIAL  TATIIOLOGY  AND  THERAPY  OF  INSANITY. 

great  emotional  irritability,  which,  associated  with  the  absence  of 
moral  sentiment,  leads  to  the  greatest  brntality  and  cruelty,  and  even 
favors  the  occurrence  of  pathologic  affects. 

Intellectually,  the  patient  is  normal  in  the  eyes  of  him  Avho 
considers  logical  form  of  thought,  reflection,  and  methodic  acts  as 
decisive.  The  absence  of  delusional  ideas  and  hallucinations  in  the 
disease-picture  has  also  been  emphasized  by  Prichard.  In  spite  of 
this,  and  even  in  spite  of  the  greatest  cunning  and  energy,  when  it 
comes  to  realization  of  immoral  impulses,  such  degenerates  are  in- 
tellectually weak,  unproductive,  incapable  of  actual  occupation  and 
ordered  activity,  incapable  of  a  general  education,  one-sided,  distorted 
in  their  ideas,  and  of  limited  judgment.  Intellectual  defect  is  never 
wanting  in  these  ethically  deficient  individuals.  Many  of  them  are 
even  actually  feeble-minded.  They  are  not  merely  without  insight 
into  the  immoral,  but  they  are  not  capable  of  recognizing  that  their 
conduct  is  positively  absurd  and  injurious  to  their  own  interests.  In 
spite  of  all  the  evidence  of  instinctive  cunning  which  they  manifest, 
they  are  astonishingly  negligent,  at  the  same  time,  in  the  most  ele- 
mentary rules  of  prudence  in  committing  their  criminal  acts.  These 
defective  individuals  are  not  only  irrational,  but  they  are  also  want- 
ing in  practical  sense.  Their  highest  intellectual  Avork  is  always  de- 
fective, even  when  it  is  in  the  form  of  that  which  is  vulgarly  called 
reason.  They  have  not  certain  fundamental  ideas,  and  the  cor- 
rectives as  well  as  the  faculty  to  recognize  the  end  and  meaning  of 
life  are  wanting.  This  fact  is  manifest  in  business  affairs.  They 
know  the  value  of  money  as  money,  but  not  its  value  and  importance 
in  material  and  social  interests.  They  throw  it  away  like  children. 
These  defects  result  fatally  in  absence  of  eff'ort  with  a  determined 
purpose. 

Formally,  in  the  domain  of  ideation,  along  with  the  incapability 
of  forming  ethic  ideas  and  associating  them  in  the  formation  of 
moral  judgments  and  notions,  the  defective  power  of  exact  reproduc- 
tion of  ideas  is  to  be  noted  (page  69). 

On  the  side  of  the  will,  the  ethic  and  intellectual  defect  mani- 
fests itself  in  the  complete  absence  of  power  of  self-direction  and 
control.  In  general,  these  degenerates  are  noticeable  for  their  lack 
of  mental  tone  and  laziness,  which  are  overcome  only  for  the  satis- 
faction of  their  immoral  or  criminal  instincts.  They  are  born  vaga- 
bonds, moral  weaklings;  tramping,  begging,  and  stealing  are  their 
favorite  occupations;  work  is  a  burden. 

Owing  to  the  absence  or  the  inexcitability  of  moral  ideas,  free- 
dom of  action  is  reduced  to  the  level  of  arbitrary  acts  which  are, 


AEREST  OF  PSYCHIC  DEVELOPMENT.  625 

however,  not  morally  free;  and  to  their  eyes  afflicted  with  moral 
blindness,  the  most  elevated  commands  of  moral  law  and  justice  are 
only  useless  and  incomprehensible  legal  restrictions.  In  addition  to 
this  state  of  affairs  there  is  also  very  frequently  to  be  considered  the 
fact  that  organic,  spontaneous  impulses,  brought  directly  into  activ- 
ity by  the  brain  anomaly,  impel  these  individuals  to  strange,  immoral, 
or  criminal  acts. 

They  have  still  other  marks  of  psychic  degeneracy:  impulsive 
characteristics,  frequently  of  periodic  recurrence  (vagabondage,  theft, 
alcoholic  and  sexual  excesses).  Since  natural  instincts  are  the  cause 
of  acts,  these  instincts  may  take  on  the  character  of  perversity.  This 
is  especially  the  case  with  the  sexual  instincts,  the  perversions  of 
which  are  usually  based  upon  moral  insanity.  Since  we  have  to  deal 
here  with  conditions  of  individual  degeneracy,  the  clinical  phenomena 
are  extremely  varied  and  do  not  lend  themselves  to  more  detailed 
differentiation. 

In  accordance  with  variations  in  the  intensity  of  the  disturbance, 
we  may  differentiate  conditions  of  moral  imbecility  and  moral  idiocy, 
comparable  with  states  of  intellectual  imhecility  and  idiocy.  Prac- 
tically we  may  also  distinguish  between  passive  and  apathetic,  active 
and  irritable,  moral  idiots. 

Moral  insanity  is  essentially  a  stationary  infirmity.  The  proc- 
esses of  puberty,  sexual  and  alcoholic  excesses,  may  have  a  bad  effect 
and  awaken  perverse  impulsive  instincts.  Moral  idiots  are  much  dis- 
posed to  react  in  a  psychopathic  way  to  injurious  influences.  Confine- 
ment, especially,  suffices  to  induce  intercurrent  actual  insanity. 

Aside  from  states  of  pathologic  affect  and  intoxication,  not  in- 
frequently periodic  psychoses  are  observed  as  complications  of  moral 
insanity,  and  I  have  also  observed  cases  of  paranoia. 

The  prognosis  of  moral  insanity,  since  it  is  a  congenital  infirmity, 
is  hopeless.  However,  it  is  to  be  remembered  that  signs  of  moral 
insanity  in  childhood  and  youth  may  develop  in  association  with 
epilepsy  or  trauma  capitis,^  and  with  removal  of  the  cause  the  mental 
defect  may  disappear.  The  prognosis  of  these  acquired  and  symp- 
tomatic cases  is  therefore  not  absolutely  bad. 


^  Thus  Wigand  (on  the  duality  of  mind)  relates  a  case  of  a  young  person 
who  was  struck  on  the  head  with  a  ruler  in  the  hands  of  a  teacher.  There 
Avas  complete  transformation  of  the  patient's  moral  feeling.  At  the  seat  of 
the  injury  the  skull  was  trephined  and  a  slight  depression  of  the  skull  found. 
Splinters  of  bone  were  removed  which  pressed  upon  the  brain,  and  the  patient 
was  restored  to  his  previous  condition. 

40 


626  SPECIAL  TATUOLOGY  AND  TIIERArY  OF  INSANITY. 

The  diagnosis  of  these  conditions,  especially  in  medico-legal 
cases,  is  very  important,  and  the  task  is  one  in  which  the  clinical 
anomalies  must  be  shown  to  depend. upon  congenital  defective  brain 
organization.  The  fulfillment  of  this^  requirement  is  indispensable. 
The  monstrosity  of  a  man's  mental  make-up,  the  proof  of  moral 
defect,  are  not  sulTicient;  these  may  be  quite  as  ii\uih  the  result  of 
defective- education  as  of  defective  organization.  The  general  psy- 
chologic criteria  do  not  give  much  aid  here.  The  examination  must 
be  strictly  clinical,  and  it  is  well  at  first  to  leave  aside  the  special 
diagnosis  and  ascertain  the  existence  or  not  of  a  cerebral  abnormality 
from  a  general  standpoint  (ride  page  231). 

The  decisive  points  indicating  moral  insanity  arc: — 

1.  Insane,  drunken,  or  epileptic  parents. 

2.  The  existence  of  anatomic  and  functional  signs  of  degeneracy, 
with  special  consideration  of  the  condition  of  the  sexual  life  as  the 
most  important  organic  foundation  of  the  development  of  the  moral 
sense. 

3.  The  existence  of  signs  of  an  abnormal  state  of  the  vasomotor 
(intolerance  of  alcohol,  etc.)  and  motor  functions  (especially  the 
epileptoid  symptoms  which  are  frequent  in  these  cases).   • 

If  it  be  possible  to  make  a  general  diagnosis  of  a  cerebral  malady, 
then  the  task  in  special  diagnosis  is  to  prove  the  abnormally  early 
manifestation  of  ethic  deformity  at  a  time  of  life  when  the  influence 
of  bad  example  could  not  be  brought  in  question,  and  when  the  ex- 
ternal relations  have,  as  is  often  the  case,  been  favorable  (positive 
efforts  at  proper  education).  That  the  anomaly  is  due  to  organic 
conditions  is  further  sustained  by  the  absolute  incorrigibility  of  the 
patient. 

Further  diagnostic  light  is  thrown  upon  the  moral  defect  by  the 
demonstration  of  intellectual  weakness;  abnormal  emotional  irrita- 
bility; defective  reproduction  of  ideas;  impulsive,  .perverse  feelings 
depending  upon  natural  impulses  and  instincts ;  and  finally  the  peri- 
odic character  of  activity  so  frequently  observed. 

Treatment  with  reference  to  the  states  of  moral  defect,  unless 
we  have  to  do  with  acquired  conditions  dependent  upon  epilepsy, 
onanism,  or  trauma  capitis,  is  without  prospect  of  success.  These 
savages  in  society  must  be  kept  in  asylums  for  their  own  and  the 
safety  of  society.  In  passive,  torpid  cases  of  moral  idiocy,  years  of 
mental  training  in  such  institutions  sometimes  elevate  these  de- 
fective individuals  to  a  condition  where  they  are  capable  of  leading 
a  relatively  independent  life  outside  of  an  institution. 


ARREST  OF  PSYCHIC  :DEVEL01'MI^:NT.  G27 

Case  81. — Moral  insanity. 

F.,  aged  35,  single,  servant.  Father  was  eccentric  and  cxcitaljlc;  mother 
insane.    A  brother  had  periodic  insanity,  another  is  peculiar. 

At  birth  the  patient  was  weakly,  sickly  as  a  child,  and  was  greatly  dis- 
turbed by  emotions.  She  was  of  small  mental  endowment,  could  not  be 
taught,  cross,  obstinate,  very  irritable,  unsocial,  gluttonous,  inconstant,  in- 
capable of  continuing  any  work,  coarse,  without  feeling,  and  giv(tn  only  to  tlie 
satisfaction  of  her  moods.  Menses  at  17  without  difficulty.  At  the  age  of  10, 
after  the  death  of  her  parents,  she  had  to  work  out.  She  remained  in  no  place 
long,  was  dismissed  usually  after  a  short  time;  for  she  was  lazy,  mendacious, 
\  chasing  after  men,  and  given  to  prostitution.  All  efforts  of  her  respectable 
family  to  induce  her  to  act  otherwise  were  in  vain.  She  spent,  in  gormandiz- 
ing and  amusements,  money  which  her  brothers  and  sister  gave  her.  She  did 
the  same  thing  with  what  she  earned,  whether  it  was  in  service  or  by  prostitu- 
tion. ,Feelings  of  self-respect  or  of  affection  for  her  relatives  were  unknown  to 
her.  Only  v/hen  she  had  nothing  did  she  seek  her  relatives  in  order  to  make 
demands  on  them.  On  account  of  her  dissolute  life  she  frequently  had  en- 
counters with  the  police,  for  she  offended  public  decency  and  gave 'no  attention 
to  police  regulations.  She  found  nothing  improper  in  her  manner  of  life. 
Wlien  finally  she  could  get  work  nowhere  her  relatives  took  her.  Soon  it 
became  impossible  for  her  to  remain  in  this  respectable  family  because  of  her 
filth,  negligence,  laziness,  bad  manners,  brutality,  and  senseless  wasting  of 
money.  She  went  about  with  her  clothing  in  rags,  without  washing  herself, 
threw  lighted  matches  on  the  floor  without  paying  any  attention  to  them,  and 
even  would  solicit  men  at  night  before  the  door.  Finally  the  family  recognized 
that  they  had  to  deal  with  an  unfortunate,  and  abandoned  her. 

She  went  about  in  the  lowest  places  until  one  day  she  was  arrested.  At 
this  she  broke  forth  in  pathologic  anger,  began  to  rave,  and  she  was  put  in 
the  section  for  observation  in  the  hospital.  There  she  played  the  injured 
innocent,  paid  no  attention  to  the  regulations  of  the  house,  incited  other 
patients  to  mischief,  had  constantly  explosions  of  anger  in  her  great  irrita- 
bility, always  about  her  affair  with  the  police.  The  police  were  her  enemies, 
and  tried  to  injure  her,  though  she  had  never  done  wrong.  Of  her  moral 
defect  and  her  inability  to  direct  herself  she  had  no  idea.  All  the  unpleasant 
experiences  she  had  had  in  her  life  she  attributed  to  the  meanness  of  other-- 

The  patient  is  of  middle  height,  extremely  ugly,  of  coarse,  sensua  jiea- 
tures.  Moral  degeneracy,  commonness,  and  frivolity  are,  so  to  speak,  written 
on  the  patient's  countenance.  The  brow  is  narrow,  flat,  the  root  of  the  nose 
deep,  the  nasal  bone  wide  and  flat.  Mimic  contracture  of  the  muscles  of  the 
left  corner  of  the  mouth. 

The  patient  is  heavy  in  movement,  has  a  shuflfling  gait,  and  scarcely  takes 
the  trouble  to  lift  her  feet  properly.  The  slightest  thinn-^i  oause  her  to  come 
in  conflict  with  those  around  her  and  she  bursts  forth  into  anger  that  in  in- 
tensity and  duration  far  surpasses  physioloc;!'  limits.  Her  power  of  ideational 
reproduction  is  defective,  and  her  description  of  events  is  incorrect,  even  when 
she  has  no  interest  in  distorting  them.  The  patient  is  impossible,  coarse  to 
brutality,  afraid  of  work,  tries  to  persuade  others  not  to  work,  goes  about 
disturbing  and  scolding  others,  trying  to  attract  men,  and  demands  her  dis- 
charge; but  she  cannot  say  what  she  will  do  when  she  is  put  at  liberty.  The 
patient  was  transferred  to  an  institution  for  chronic  insane. 


IISTDEX. 


Abortion,  191 

Absinthe,  196 

Abstinence,  sexual,  188 

Abulia,  93 

Abuse  of  alcohol  and  insanity,  512 

Acetonemia,    198 

Acid,   salicylic,    as   a   cause   of   psychoses, 

195 
Acts,  affective,  20 

impulsive,   20,   87 

psychic   reflex,    in    melancholia   and   de- 
lirium, 90 
Affects,   18,   30 

expectant,  57 

mixed,  of  anger,   57 

pathologic,  30,  56,  212 

surprise,   57 
Age  and  insanity,  144 

and    the   prognosis    of    insanity,    221 

childhood,    145 

climacteric  and  old  age,   151,   152 

maturity,  151 

puberty,  146 
Agoraphobia,    64 
Agraphia,    103 
Albuminuria,   131 

Alcohol,  modern  abuse  of,  140,  213 
Alcoholism,   acute,    34 

chronic,    512 

complications,    518 

delirium   of   drunkenness,    525 
tremens,   519 

delusions   of   jealousy,    513 

epilepsy,    538 

fundamental  mental  symptoms,  512 

hallucinations,   525 

hallucinatory   insanity,   533 

mania    gravis    potatorum,    529 

melancholia    potatorum,    527 

motor   disturbances,    515 

paranoia,    536 

premature  senility,  517 

prognosis,    517 

pseudo-paralysis,     537 

sensorial   anomalies,    515 

sensory  anomalies,   516 

sexual  symptoms,  516 

treatment,   517 

visual  disturbances,  520 
Alexia,   103 


Allegorization  of  sensations,  75 
Amaurosis,  120 
Amblyopia,   120 
Amnesia,  67 

partial,  68 
Amonomania,  51 
Amyl    hydrate,    265 

nitrite,    258 
Anaesthesia  sexualis,   81 
Analgesia,   120 
Analogies  of  insanity,   27 
Anaphrodisiacs,   266 
Anatomy,   pathologic,   21,  277 
Androgyny,   85 
Anemia,   180 

as  a  cause  of  insanity,   180 

in   the   insane,    217 

prognosis    224 
Anenergy,  93 
Anesthesia,  esthetic,  55 

psychic,  53 
Anesthesias,   cutaneous  and  muscular,    120 

of  general  feeling,  120 

of  the  sense-organs,   119 
Anorexia,   80 
Anosmia,  120 
Anxietas  tibiarum,   122 
Anxiety  (fear),   57 

in    hysteric    insanity,    493 

in  melancholia,  292 

precordial,  127 

psychic  significance  of,  127 

transitory  states  of,   210 

treatment   of,    270 
Aphasia,  103 
Apoplexy,    cerebral,   167 

prognosis  of,  167 

with  insanity.  224 
Apperception,   diminished,  66 

increased,  66 
Appetite,    anomalies   of,    79 

diminution  of,    SO 

perversions  of,   80 
Arteries  of  brain,  6 

therapeutic  dilatation  of,   257 
contraction  of,  257 
Artists,  155 

Assimilation  in  insanity,   134 
Association  of  ideas,   17 

disturbances  of,   60,   94 


(629) 


630 


INDEX. 


Atavism,   158 

Atheroma  of  the  cerebral  vessels,  1G7 
Atropine  as  a  cause  of  insanity,  194 
Attention,    95 
want  of,  113,  119 

Basedow's  disease,    172 
Haths,    lukewarm,    2G2 

prolonged,   2G:{ 
Belladonna,  as  an  anaphrodisiae,  266 

mental    disturbances    due    to,    194 

therapeutic    value    of,    261 

used  tor  hyperesthesia  of  the  rectal  mu- 
cous  membrane,   2G9 
Bleeding,    255 
Blindness,  mental,  66 
Blood-relationship    as    an    hereditary    dt-- 

generative   factor,    160 
Bodies,  foreign,   and  the  insane,   218 
Bones,  fragility  of,   in  the  insane,  218 
Brain,  anatomy  of,   2 

as    the    place    of    origin    of    psychic    ac- 
tivity,   2 

convolutions  of,   3 

diseases  of,   as  causes,  107 

elementary    functional    disturbances    of, 
48 

focal    diseases    of,    167 

ganglion-cells  of,  as  substratum  of  psy- 
chic  life,   8 

histology  of,   2 

motor   areas   of,    9 

pathologic   changes   of,    in   insanity,    21 

perceptive   centers    of,    11 

weight    of,    3 
Bromides,    261 

as    hypnotics,    266 
Bromism,    197 
Bulimia,  79 

Cachexia  strumipriva,    193 
Camisole,    269 
Camphor,   258 

monobromate,    264 
Cannabis  Indica,  194,  266 
Carbon    disulphide,    198 
Carbuncle,    218 
Catalepsy,   91 

Catarrh,    intestinal,    in    the    insane,    218 
Causes,    cardiac   diseases   as,    18:'. 

chronic    local    diseases    as,    181 

effect  on   prognosis,    224 

of  psychoses,  136 

predisposing,  138 

psychic,    165 

somatic,   165 
Central    nervous    system,    anatomy    of,    2 
Character,    pathologic,    159 

changes  of,   in  the  insane,  237 


Childbearing,   frequent,    188 
Childhood,    insanity    in,    145 
Child-prodigies,   164 
Chloral   hydrate,    265 

abuse  of,  196 

contra-indications,   265 

in  precordial  distress,  271 
Chloroform,    psychoses   due    to,    19G 
Chlorosis,   146 

Cholera,   psychoses  due  to,  179 
Chorea  minor,  171 
Civilization  and  insanity,  138 
Classification   of  insanity,   277 

from    a    clinico-functional    standpoint, 
281 

from   an   anatomic   standpoint,    278 

from  an  etiologic  standpoint,  278 
Climacteric   in  the  male  sex,   151 
Climate  and  insanity,   141 
Cocaine,    195 
Codeine,   261 
Condition,   civil,    144 
Confusion,  general   (dementia),  356 
pseudo-aphasic,  62 
psychic  exhaustion,  61,  100" 
Conium,  194,  261 
Consciousness,    clouding   of,    91 

epileptic,  479 

in  delirium  after  alcoholic  indulgence, 
215 
Consciousness,   self-,  14 

alternating,   98 

elementary   disturbances   of,   95 
Constipation  in  the  insane,  269 
Constitution,   neuropathic,   163 
Contagion,  psychic  (imitation),  166 

prognosis   in  cases  due   to,    225 
Convalescence   from   insanity,    135 

treatment  during,  275 
Coprophagia,    80 
Cord,   spinal,   disease  of,   170 
Course  of  insanity,   199 
Creeds  and  insanity,   143 
Cretinism,   Gil 

Curability,    prognosis   of,    in    insanity,    221 
Cure,  diagnosis  of,  239 
Cysticercus,   168 

Datura   stramonium,    194 
Deaf-mutism,   102 
Deafness,   mental,   103 
Decubitus   in   the   insane,    218 
Degeneracy,   psychic,   in  general,  280 

classification    of,    283 

general  clinical   consideration  of,  359 
Degeneration,  signs  of,  129 
Deliria,    i)rimordial,   74 
Delirium,    73 

acute,  546 


INDEX. 


631 


Delirium,  anatomic  findings,   516 
clinical   description,   548 
diagnosis,  552 
differential  diagnosis,  552 
etiology,    547 
in  acute   diseases,    174 
metabollcum,   76 
nature  of,  546 
of  transitory  mania,  207 
pathogenesis,   547 
prognosis,    552 
terminations,  552 
traumaticum,   171 
treatment,  553 
tremens,    519 
opium    in,    524 

pathology  and  treatment  of,  520 
Delivery,    insanity    due    to,    189 
Delusions,  71 
as    a   transformation,    375 
in    paranoia,    374,    382 
of   grandeur,    375 
of  jealousy,  393    ■ 
persecutory,    75 
treatment  of,    272 
bromides,    387 
morphine,   387 
opium,  259 
value  of,   in  diagnosis,   238 
Dementia,  agitated,  355 
anatomic    findings,    603 
apathetic,    356 
Initial  symptoms,   603 
paralytica,   557 
apoplectiform  attacks,  573 
diagnosis,  differential,  575 
disturbances  of  the  ocular  muscles,  571 
of  deglutition,   572 
of  handwriting,  571 
of  sensibility,   574 
of  speech,  570 
of  the  facial  muscles,  572 
of  the  vocal   cords,   571 
of  temperature,   575 
sensorial,   574 
trophic,    574 
vasomotor,   573 
duration,    578 
epileptiform   attacks,   573 
etiology,    579 
final   stage,   563 
galloping  paralysis,  578 
general   description  and   course   of,  557 
hypochondria,   568 
infantile,    juvenile,    581 
maniacal   attacks,   566 

states,   565 
melancholic  states,  567 
micromania,  568 


Dementia   paralytica,    motor   disturbances 
In,  569 
In   the  extremities,   572 
nature    and    definition    of    the    disease, 

557 
outbreak  of  the  disease,  558 
post-mortem   findings,   564,   584 
primary  progressive  dementia,  5G9 
prodromal   stage,   558 
prognosis,  578 
psychic   symptoms,   565 
recoveries,  579 
remissions,   569 
sexual   impulse,    574 
synonyms,  557 
primary  acute   (curable),   330 
senile,    603 
stage  of   full    development,    course,    and 

terminations,    604 
terminal,    355 
Demonomania    75 

prosecution  of  witches,   39 
Development,  psychic,  arrest  of,  285,   609 
Diagnosis  at  the  bedside,  231 
changes  of  character,  237 
delusions,    238 
diagnostic  principles,   232 
general,    231 
hallucinations,  238 
handwriting  of   the  insane,   236 
in   court,   231 
of    idiopathic    and    sympathetic    mental 

disease,   239 
of  recovery,  239 
of  the  disease,   231 
outline  of  examination,    240 
personal    examination,    235 
Dietetics,  somatic,  276 
Digestion  and  assimilation  in  the  insane, 

134 
Digitalis,   256,  264 
Dipsomania,   434 

Diseases,  acute  constitutional  as  causes  of 
psychoses,  173 
chronic  constitutional,  in  the  psychoses, 
ISO 
local,   as  cause  of  insanity,   181 
intestinal,  as  causes  of  insanity,  182 
mental,  notion   of,   1,   20 
of  the  sexual  organs,  female,  183 

male,   185 
special  place  of,   20 
Displeasure,  feeling  of,  93 
Disposition  to  insanity,   congenital,   157 
Dissimulation,   239 

Disturbances,   elementary  psychic,   48 
prognosis  of,  224 
psychomotor,  88 


632 


INDEX. 


Disturbances,  sympathetic  psychic,  224 

trophic,  and  anatomic  signs  of  degenera- 
tion after  affections  of  the  brain, 
129 

vasomotor,  126 
Douches,  263 

Dreams   and   insanity,   33 
Dream-states   of   waking   life,   99 

pictures,  reproduction   of,   68 
Drunkenness,   34 

taint  due  to,   at  the  moment  of  concep- 
tion, 160 
Duboisine,   262 

Duration  of   insanity,   prognosis,   204 
Dysesthesia,    psychic,    50 
Dysphasias,  103 
Dysphrasias,  101 
Dysthymia,  123 


Ears,   disease  of,   169 

Echo  speech,   101 

Ecstasy,  100 

Education  of  tainted  children,  248 

errors  in,  164 
Effemination,  85 
Ego,   a  new,   representing  delusions,   97 

multiplication    of,    97 
Emotions,    anomalies   in   the   intensity   of, 
48 

abnormal  dullness  of,  53 
irritability    of,    52 

as   cause,   165 

disturbances  in  the  occurrence  of,  50 

pathologic  states  of,   212 

physiologic  states  of,   48 

prognosis   in   relation   to,   225 
Emotivity,   psychic,    52,   513 
Epilepsy,   172 

chronic  psychoses  in,  490 

clinical  limitation  of,   472 

epileptic  character,  474 

diagnosis  of,   486 

mental  equivalents   of   epileptic   attacks, 
472 
prodromes,  474 

nocturnal,  473 

pathologic  anatomy  of,  490 

peculiarities  of  character  in,  474 

post-epileptic  symptoms,  475 

prognosis,   490 

protracted   mental    equivalents,    4SG 

symptoms  of  the  interval,  473 

transitory  attacks  of  mental  disturoance, 
477 

treatment,  491 
Erethism    of    the    brain,    CG 
Ergotine,   257 
Erotomania,    408 


Erysipelas,  facial.  In  the  insane,  218 

of  the  head,  177 

psychoses  due  to,  177 
Exaltation,    states   of,   07 

maniacal,    313 
Examination,  personal,  235 

plan  for,  240 
Excandescentia  furibunda,  5G 
Excesses,  alcoholic,  194 

prognosis,  224 

sexual,  as  a  cause  of  psychoses,  185 
Excitability,     alterations    in     the    sensory 
centers,  105 

increased,   106 
Excitation,    physiologic,    16 
Excitement,  sexual,  anaphrodisiacs  in,  266 

bromides  in,  266 
Exhaustion,   states  of,   61 

Faradization,    general,    267 
Fat-embolism  in  the  insane,   218 
Feeding,  forced,  270 
Feeling,   contrary   sexual,   85 
Feelings,    abnormal,    48 

abnormal  coloring  of,  57 

ethic,   18 

hallucinations    of,    117 

pleasant  and  unpleasant,  17 
Fetichism,   84 
Fever,    intermittent,    psychoses  after,   177 

delirium  of,  174 
Folie  raisonnante,  365 
Food,  refusal  of,  269 
Free  will,   20 

absence  of,  95 
Functions,  motor,  disturbances  of,  124 
Furunculosis  in  the  insane,  21S 

Gangrene  of  the  lungs  in  the  insane,  211 

Gas,   carbonic  oxide,  198 

Gases,  poisonous,  198 

Genius,   31,  160 

Governesses,  154 

Gravidity,   189 

Growth,   abnormally  rapid,   146 

Gynandry,   85 

Hallucinations,    auditory,    116,    271 

correction  of,   109 

course  of,  106 

epidemic   occurrence   of,   109 

gustatory,  117 

nosologico-psychologic  significance  of, 
108 

occurrence  of,  in  various  forms  of  in- 
sanity, 115 

olfactory,   117 

origin  of,  104 

possible  with  mental  health,  109 


INDEX. 


63 


Hallucinations,  reflex,  108 

signs   of,    110 

social  and  historical  significance  of,   110 

treatment  of,  271 
by  morphine,  271 

value  of,  in  diagnosis  of  psychoses,  2.18 

visual,   116 
Handwriting,    236 
Haschisch,  194 

Heart,    diminution    of    action    of,     thera- 
peutically,    256 
Heat-stroke,  169 
Hebephrenia,   147 
Hedonia,  51 
Hemianesthesia,  120 
Heredity   and  insanity,   157 
Hermaphroditism,  psychosexual,  85 
History,  family  and  personal,  240 

of  psychiatry,  36 
Hospitals  (asylums  for  the   insane),  252 
Hunger,  79 

Hydrophobia,   mental  origin  of,   122 
Hydrotherapy,  256-258,  262 
Hyosclne,   therapeutic  use  of,   262 
Hyoscyamus,   194 
Hyperalgia,   psychic,  52 
Hyperbulia,  94 
Hyperesthesia,  esthetic,  52 

ethic,   53 

of   cutaneous  sensibility,    121 

of  general  sensibility,   122 

of  the  higher  sensory  centers,   106 

psychic,  52 

sexual,  81 
Hyperhedonia,    psychic,    52 
Hypermnesia,  67 
Hyperorexia,  79 
Hypochondria,   172 
Hysteria,  172 

Ideas,    facilitated    transformation    of,    into 
motor  impulses,  94 
flight  of,  60 
imperative,    63 
content  of,   459 

distinction  from  paranoia,  458 
episodic,    in  melancholia,   462 
fear,  461 
general  causal  conditions  in,   458 

course,  462 
influence  upon  action  and  feelings,  461 
manner  of  origin  of,   461 
mental    disturbance    due    to,    457 
reactive   influence  upon   the   emotions, 

461 
terminations   of,  463 
treatment  of,  463 
Inhibition     of     transformation     of,     into 
motor  acts,  93 


Ideas,  motor,  10 

procession  of,   17 
Idiocy,   anatomic  findings,   612 
causes    of,    during    years    from    birth    to 

puberty,  611 
clinical   consideration   of   idiots,  009 
conditions  of  origin,  609 
course   and   prognosis  of,   620 
intellectual,    causes   of,    610 
moral,  description  of,  621 
acquired,   complications  of,   012 
classification  of,   16,   624 
clinical  marks  of,  623 
complications   of,   624 
diagnosis,  626 
intellectual   defects,  624 
passive,  apathetic,  and  active  irritable, 

625 
prognosis,  625 
treatment,    626 
prenatal  causes  of,  610 
prophylaxis,  621 
psychic  defects,   616 

symptoms,    616 
somatic  symptoms,  619 
treatment  of,  621 
Illusions,    physiologic,    physical,    and   psy- 
chic, 111 
affective,  113 
Imagination,   17 

anomalies  of,   70 
Imitation  as  a  causal  element  in  insanity, 

166 
Impressionability,   increased,  52 
Imprisonment   and  insanity,   156 
Inanition,    states   of,   105 

delirium  of,   174 
Inbreeding,    158 
Incubation,  symptoms  of,  199 
melancholic  stage  of,  201 
treatment  of,  250 
Individualization  in  treatment.   247 
Inhibition  in  the  psychic  mechanism,   93 
Insanity,   acute  hallucinatory,    340 
causes  and  origin  of,  340 
conditions   of   origin    of,    340 
confusion  in,   343 
delirium  in,  342 
differential  diagnosis,   346 
duration   of,*  345 
nature  of,   341 
periodic,  424 
prognosis,  345 
prophylaxis,   347 
reactive    manifestation    in    feeling   and 

action,   344 
recovery  in,   345 
remissions  and  exacerbations,  344 


634 


INDEX. 


Insanity,     acute     hallucinatory,     somatic 
symptoms  in,  345 

stage   of   incubation   of,    342 

terminations  of,  345 

treatment   of,   347 
and  the  seasons,   141 
and  the  unmarried  state,   144 
chronic,    199 

circular,    nature   of  symptoms   of,    413 
constitutional    iiffective,    365 
diagnosis,  41U 
due   to  meningitis,    167 

prognosis  of,  1^24 
duration,  204 

of  the  cycle,  416 
epileptic,   472 

character  of,   472 

chronic  psychoses,   490 

diagnosis,  486 

forms  of,  475 

hallucinatory  persecutory  delirium,  480 

protracted   equivalent,   4S0 

psychic  degeneration,   475 

states  of  clouded  consciousness,  479 

transitory,  477 
epileptic  stupor,  478 

with    dreamy    romantic    ideas,    usually 
of    expansive   content,    484 

■with  fear,  473 

with    moria-like    excitement,    485 

with  religious   expansive   delirium,  482 
general  course,  199 
hypochondriac,  505 

dementia    following,    509 

paranoia,   511 

pathology    and   treatment   of,   506 
in  married  women,  144 
inheritance  of,  157 

of  Inclination  to   crime,   159 
menstrual    periodic,    438 

manner  of  origin,   438 

prodromes  of  outbreak  of,  439 

prophylaxis,   441 

spontaneous    temporary    cessation     of, 
440 

treatment,   441 

typical    recurrence,    440 
mental  causes  of,  165 
moral,  621 

diagnostic    features   of,    231 

hysteric,   492 
character,    elementary    psychic    dis- 
turbances,   492 
division  of,  493 
ecstatic  visionary  states,   494 
psychoses,  500 

hystero-epilpptic   deliria,   494 

moria-like   states,  494 

pellagrous   (ergot),  195 


Insanity,  protracted  states  of  hysteric  de- 
lirium,   497 
states      of       apprehensiveness,       with 

clouded  consciousness,  494 
transitory    hysteric,    493 
periodic,  204,   413 
arising   sympathetically,    438 
idiopathic,    in    the    form    of    abnormal 

impulses,    433 
In    the   form   of   a   psychoueurosis,    417 
pathogenesis,    413 
prognosis,   416 

of  inheritance,  228 
querulous,    394 

according  to  age,  221 
to   course,    222 
to   duration,   222 
to  etiology,  223 
to  psychic  symptoms,   225 
to  single  physical  symptoms,  226 
curability,    221  '  , 

of    life,    220 
senile,   152 
regeneration,    162 
subacute,  199 
tainted   family   tree,    101 
termination,   204 

the   classification  of  psychoses,   277 
transitory,   206 
Instinct,   sexual,   anomalies  of,   81 
diminution   and  absence  of,   81 
perverse  intensification   of,   83 
Interval,  lucid,  205 
Intoxication,  insanity  due  to,  192 
Iodoform,   195 
Iracundia   morbosa,    56 
Isolation  of  patients,   272 

Judgment,  deliria  of,  114 

Kidneys,   disease  of,   as  cause  of  insanity,' 
183 

Lactation,   insanity   of,    191 

prognosis,  224 
Lead   psychoses,   196 
Life,    in   war,    156 

unconscious   mental,    96 
Localizations  in    the   cerebral   cortex,   12 
Logorrhea,  101 
Lues,   cerebral,   594 

anatomic  findings,  594 

course,  597 

cures,  597 

development  of,   595 

diagnosis,    596 

symptoms,  595 

terminations,   597 

treatment,  597 


INDEX. 


635 


Lupulin,  266 
Lust,   abnormal,   5 

Mania,   312 
abnormal  acts  in,  315 
occurrence  and  course  of,  316 
physical  symptoms,  31G 
prognosis,  317 
psychic  symptoms,  313 
therapy,  317 
acute,    323 

physical    symptoms,    321 
acute  transitory,  207 
anomalies  of  mood  and  thought,  313 
differential     diagnosis     from     hallucina- 
tory Insanity,  346 
from  agitated  dementia,  356 
frequency,    322 
furious,  319 
hallucinations,  320 
impulsive  movements  in,  321 
in  childhood,  145 
maniacal  exaltation,   313 
nature  of,  319 
origin  and  course,  323 
periodic,  417 
duration   and   course,   418 
prodromes,  417 
prognosis,  419 
symptoms,  418 
treatment,  420 
prodromal  stage,  323 
prognosis,  325 
puerperal,   191 
recovery,  324 
senile,   153 

sexual  excitement  in,  321 
terminations    of,    324 
therapeutic  indications,  325 
transitional  stage   to  recovery,   324 
Marriage  and  insanity,   144 

of  blood-relations,   160 
Masochism,   84 
Mastoid,  168 

Means  of  diminishing  flow  of  blood  to  the 
brain,  255 
of  increasing  flow  of  blood  to  the  brain, 
257 
Measles,    psychoses   due   to,   177 
Medico-legal,   26 
Melancholia,   286 
active  or  agitated,  291 
anomalies   of   the   urine  in,    130 
consciousness  of   inhibition  in,  287 
course  and  termination  of,  308 
delusions  in,   288 
demonomaniacal,    302 

differential  diagnosis  from  hallucinatory 
insanity,   346 


Melancholia,   disturbances   of   thought   in 
(form  and  content),    288 

errabunda,  291 

errors  of  the  senses  in,  298 

flight  of  ideas,  292 

hydrophobica,  305 

hypochondriac,  304 

in  mental  disturbance  due  to  Imperative 
ideas,  462 

masturbatoria,  454 

melancholic  folie  raisonnante,   365 
treatment  of,   366 

nature  of  the  disease,  286-287 

passive,    291 

periodic,    421 

precordial,  295 

psychic   anesthesia  in,   287 
dysesthesia  in,  287  ■  i 

hyperesthesia  in,  287 
symptoms,  286 

psychomotor  disturbances  in,  289 

puerperal,  191 

raptus   melancholicus,   210 

religious,  301 

senile,   152 

simple,  290 

somatic  symptoms,  289 

stuporous,   or   attonita,   305 

suicide   in,    292 

syphilophobica,    304 

treatment  of,  310 

without  delusions,   293 
Memory,  14 

disturbances    of,    66 

errors   of,    67 

illusions  of,  69 

phantasms  of,  69 

weakness  of,  225 
Menstruation  and  psychoses,   184 

disturbances   of,   in   the  insane,   133 

prognosis,  224 
Mercury,  psychoses  due  to,  197 
Metabolism  in  the  insane,  135 
Metritis,   chronic,   183 
Misanthropy,  58 
Misery  and  insanity,   139 
Morbidity,  216 
Moria,   324 
Morphine,  260 

as  an  hypnotic,   263 

contra-indications,    261 

employment  of,   in  hallucinations,    271 
Morphinism,    540 

symptoms  of  abstinence,   542 
of  intoxication,   543 

treatment,    543 
Movements,  impulsive,  of  the  maniacal,  87 

abundance  of  motor  motives,   94 

reflex,  19 


63G 


INDEX. 


Movements,   reflex  psychic,   94 
Mushrooms,    poisoning    by,    194 
Mutism,   102 
Myxedema,   198 

Narceine,  261 

Narcotics,  insanity  due  to,  194 

in  the  treatment  of  psychoses,   238 
Nationality   and    insanity,    141 
Nerves,    peripheral,    affections   of,   170 

injury  of,  170 
Neuralgias,   123 

psychic,  49 
Neurasthenia,   psychoses  in,   452 

insanity  due  to  imperative  ideas,  437 

melancholia  in,   434 

paranoia,   4G6 

transitory  insanity  in,  452 
Neuropsychoses,  prognosis  of,  221 
Neuroses,    constitutional,    as   the   basis  of 
insanity,   171 

Inheritance  of,  159 

neuropathic  constitution,   163 

neuropathies.    171 
Nicotine,   psychoses  due  to,   195 
Nutrition  in  the  insane,  136 
Nux  vomica,  2G7 
Nymphomania,  82 

Occupation  as   a  cause  of  mental   disease, 

154 
Onanism  as  a  cause  of  insanity,  18C 

treatment   of,    206 
Operations  on   the   eye   as   a   cause   of  de- 
lirium,  166 
Opium,  abuse  of,  194 

therapeutic  use  of,  258 
Othematoma,   218 
Overburdening  of  youth,  164 
Overexertion,   mental,    164 

Packs,    Priessnitz,    2G3,    266 
Papaverine,   261 
Paradoxia  sexualis,   86 
Parsesthesia  sexualis,   83 
Paragraphia,    103,    237 
Paraldehyde,   265 

abuse  of,  196 
Paralgia,  57 
Paralysis  agitans,   172 

progressive  lead,   197 
Paramimia,    125 
Paramnesia,   69 
Paranoia,    368 

acquired   (late)  typical  form,  381 

alcoholic,   536 

delusions  of   being  watched,   382 


Paranoia,  delusions  of  Jealousy,  392 

diagnosis,   369,   387 

differential  diagnosis  from  hallucinatory 
insanity,  385 

erotic,   408 

errors  of  the  senses  in,  374 

etiology   of,   371 

exciting  causes,   373 

fundamental  symptoms  of,   371 

general  course  and  terminations,   375-376 

grand  delusions,   375 

hysteric,  501 

hypochondriac,   511 

manner  of  origin  of  delusions,   374 

neurasthenic,   466 

original,   377 

pathologico-anatomic   findings,   372 

persecutory,   382 
delusions  in,  371,  382 

premorbid  peculiarities,  371 

reformatory,   399 

religious,  403 

sexual,   390 

stage  of  incubation,   373 

transformation   of  the  delusions,   375 
Paraphasia,   61,   100 
Perception,   104 

imperfect,  113 

process   of,    104 
Personality,  consciousness  of,   14 

double,  98 
Persons,   mistaking  of,    114 
Perversion  of  feeling,  58 
Phrenalgia,  49 

Phrenolepsia  erotomatica,  62 
Phthisis,   psychoses  in,  181 
Physicians  and  the  study  of  insanity,  25 
Physiognomy,  expression  of,  In  psychoses, 

124 
Physiology,  experimental,  and  pathology,  8 
Pica,  58 

in  the  chlorotic,  80 
Piscidia  erythrina,   261 

Place,  consciousness  of,  disturbances  of,  97 
Pleasure  in  pain,  58 
Pneumonia  In  the  insane,   217 

insanity  due  to,  178 
Poisons,   insanity  due  to,  192 

metallic,  196 
Politics   and   insanity,    141 
Polyneuritis    and    psychoses,    178 
Polyphagia,  79 
Polyphrasia,  101 
Pregnancy,  insanity  due  to,  189 

prognosis  of,  224 
Preliminaries,  psychologic,  14 
Prognosis  of  psychoses  due  to  genital  dis- 
eases,  224 
Prophylaxis  of  insanity,   24S 


INDEX. 


637 


Pseudo-hallucinations,   69,    108 
Psyctialgia,  49 
Psychiatry,   aim   of,    1 

future  goal  of,  45 

history  of,  36 

scientific   and   social   importance   of,    24 

the    study    of,    24 
Psychoneuroses,    classification    of,    279 

distinction    from    psychic    degenerations, 
279 
Psychoses,   alcoholic,    194 

combined,    203 

due    to    influenza,    179 

febrile,  175 

opium  in,  259 

prognosis   of,    224 

reflex,  123 
Puberty  and   insanity,   145 
Puerperium  and  puerperal  psychoses,  189 

prognosis,   191,   224. 

treatment,  192 

Questioning,   impulsive,    62 
Quinine  as  a  tonic,  267 

Raptus   melancholicus,    210,   296 
Reaction  to  alcohol,  pathologic,  214 
Recurrence,  prognosis  of,  227 
Regeneration   of   tainted   families,   162 
Religion  and  insanity,  143 
Remedies,  calmative,  narcotic,  258 

physical  and  dietetic,  262 
Respiration,    disturbances   of,   in   insanity, 

134 
Rest  in  bed,  268 
Restlessness,    motor,    of    the    melancholic 

and  delirious,  89 
Rheumatism,  insanity  following,  176 

Salicylic  acid  as  an  anaphrodisiac,  266 

psychoses  due  to,  195 
Saliva,  anomalies  of,  132 
Satiety,   feeling  of,  absence  of,  79 
Satisfaction,   want  of  sexual,  187 
Satyriasis,  82 

Scarlet  fever,   insanity  due  to,   177 
Sclerosis,   multiple  cerebro-spinal,   168 
Secale  cornutum,  psychoses  due  to,  196 
Secretions,   disturbances  of,   131 
Se]f-cons»iousness,  16 
Self-feeling,   abnormal   increase  of,   57,   94 

abnormal  decrease  of,  56,  93 
Self-mutilation,  120 
Sensation,   disturbances  of,   119 
Sense-deliria,   118 

occurrence   of,    in   various    forms   of    in- 
sanity,  118 
Sensibility,    general,    anesthesias,    119 

hyperesthesias,   121 


Sensibility,  illusions  and  hallucinations  of, 
120 

muscular,   anomalies   of,   120 
Sex  and  insanity,   142 

female,  and  insanity,  142 
Shame,   loss  of  fooling  of,   and  prognostic 

significance    of,    225 
Shock,   166,   171 

Sickness,   general   feeling   of,  98 
Sitophobia,    269 
Skatophagia,   80 
Skin,  irritation  of,  257 
Skull,   anomalies  of,   130,   612 

caries  of,  169 
Sleep   in  the  insane,  135 

means  to  induce  it,  263 
Sleeplessness,   treatment  of,   263 
Small-pox  and  insanity,   176 
Soldiers,   155 
Somatose,  268 
Somnambulism,  98 
Soul,    nature    of,   1 

organ  of,  2 
Speech,    disturbances   of,    100 
Stage,    prodromal,    of   insanity,    200 

melancholic,  201 

treatment   of,    250 
States,   abnormal  emotional,  43 

gay,  51 

painful,    49 
Statistics  of  insanity,   136 
Stomach,  disease  of,  as  foundation  of  psy- 
choses, 182 
Stramonium,   261,   271 

Struggle  for  existence  and  insanity,    140 
Stupidity,  or  primary  curable  dementia,  330 

as  a  neurosis  of  exhaustion,   331 

due  to   psychic   shock,   336 
to  mechanical   shock,    338 
Stupor,   99 

epileptic,  478 
Suicide,  159 

in   melancholia,   292,   29S 
Sulphonal,  265 
Surgery  in  the  insane,  218 
Syllables,    rhyming   of,    62 
Sympathy,  18 
Syphilis,  prognosis  of,  224 

psychoses  due  to,  181 

Taint,   hereditary,   161 
Tears,    secretion  of,   131 

absence  of,   in   melancholia,   131 
Teeth,   grinding  of,   125 
Temperature,    anomalies  of,    133 
Tetany,  91 

in    convalescence,    275 

in  the  beginning  of  insanity,  250 

mental,    271 


638 


INDEX. 


Tetany,    somatic,    255 

Thought,   increased  rapidity  of,   60 

inhibition  of  the  process  of,   69 
Time,  disturbances  of  consciousness  of,  97 
Tobacco,   abuse   of,   195 

Tonics,  in  the  treatment  of  psychoses,  267 
Transformation   of   delusions   In   paranoia, 

375,    3S6 
Transmission   of  criminal   inclination,   159 
Transmutation  of  neuroses  and  psychoses, 

158 
Trauma  and  psychoses,  168 

capitis   and   insanity,    168 
prognosis  of,   224 
Treatment  by  hypnotic   suggestion,   274 
Trional,  265 
Tuberculosis  in  the  insane,  217 

in    melancholia,    181 
Typhoid,    insanity    due    to,    175 

Unrest,   muscular,   122 
Untidiness,  268 
Uremia,  198 


Urine,  secretion  of,  131 

disturbances   of,    in   the   insane,    131 
Uterus,    abnormality    and    disease    of,    as 
causes    of    insanity,    183 

Veratrum  viride,  266 
Verbigeration,   102 
Vesania   typica,    203 
Violation,   166 
Viraginity,  85 

Weakness,  mental,  states  of  secondary,  350 

congenital,    610 
Weight,  variations  of,   105,  227,   234 
Will,    diminished,    03 

distinction   of,    from   free   will,  95 

disturbances  of,   92 

increased,   94 
Witch-trials,   39 
Word-blindness,   103 
Word-deafness,  103 
Words,   formation   of  new,    103 
Worms  as  cause  of  psychoses,  182 


■'■  *=nai  I  y  LIBRARIES 


0052157636 


DATE  DUE 


Demco,  Inc   38-2 

93 

